Evergreen Nephrology · 3 hours ago
Nurse Care Manager - Post Acute (RN/PT)
United States
Full-time
Remote
Mid, Senior Level
$90K/yr - $103K/yr
3+ years expEvergreen Nephrology is dedicated to transforming kidney care through a value-based, person-centered approach. The Nurse Care Manager will be responsible for managing nephrology patients' care after hospitalization by collaborating with Skilled Nursing Facilities and ensuring smooth transitions to home or community care.
Health CareMedicalWellness
Responsibilities
Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations
Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community
Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed
Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge
Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management
Develop and implement strategies to optimize length of stay while maintaining high-quality care
Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders
Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey
Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans
Identify and develop SNF stakeholders and foster relationships for communication and coordination of care
Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions
Engage in continuous, organizational process improvement to identify opportunities and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols
Prepare reports and other deliverables to communicate program changes or developments to appropriate stakeholders
Collect data to prepare and deliver reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction
Other duties consistent with this role, as assigned
Qualification
Required
Bachelor's degree in nursing (BSN) with an active RN license or a Bachelor's or Master's degree in Physical Therapy with an active PT license; Compact License preferred where applicable
Minimum 3-5 years of experience in telephonic care management and post-acute care
Experience in Utilization Management and/or Utilization Review
Experience in specialty care including kidney care or related field
Excellent communication, problem-solving and organizational skills
Knowledge of value-based care models and strategies to reduce readmissions
Experience with team-based care and have excellent collaboration skills
Excellent working knowledge of community resources
Strong understanding of skilled nursing facility operations and regulations strongly preferred
Intermediate skills with MS Office Suite of products including Outlook and Teams
Able to work effectively in a primarily remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Benefits
Paid time off starting at 4 weeks for full-time employees
12 paid holidays per year
Medical, dental, vision and life insurance, including an HSA with employer match
Reimbursement for continuing medical education for eligible roles
A 401(k) program where Evergreen matches up to 4% of contributions
Paid parental leave
A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Company
Evergreen Nephrology
Evergreen helps nephrologists focus on the right patients at the right time across the full care spectrum.
201-500 employees
Funding
Current Stage
Growth StageTotal Funding
$134.34M2025-01-07Series Unknown· $130M
2022-06-06Seed· $4.33M
Leadership Team
John E. Donlan
Board Member and Strategic Advisor
Recent News
2025-07-05
2025-01-10
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