MDS Nurse Care Manager - Post Acute Care (CST or MST)

Who We Are 

Evergreen Nephrology partners with nephrologists and other providers to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe people living with kidney disease deserve the best care. We are committed to improving patient outcomes and quality of life by delaying disease progression, engaging patients in their own care, optimizing care delivery and transitions, and accelerating kidney transplants through partnerships with our nephrologists and other providers, best-in-class interdisciplinary clinical resources, and technology and analytics platform that enables optimized insights and care. 

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of people living with kidney disease. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You are passionate about value-based care and understand its importance in improving outcomes and reducing health care costs. You thrive in innovative and evolving environments with high rates of change. 

Your Role 

As a Post Acute Nurse Care Manager, you are responsible for collaborating with Skilled Nursing Facilities to manage nephrology patients who are receiving skilled nursing care after an acute hospitalization. This role focuses on ensuring their skilled nursing stay promotes efficiency as well as meets their specialized needs based on their individual conditions with a coordinated plan to discharge to home or community. Your job duties will include taking full ownership of patient care management within your caseload, including engaging with Skilled Nursing Facility staff, providers, patients, and their caregivers. You will perform assessments to identify needs based on individual values, goals, and preferences.

Role 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

Required Qualifications  

• Associate degree in nursing required (ASN); bachelor’s degree in nursing (BSN) preferred.
• Current RN License required; Compact License preferred.  
• Minimum 3-5 years of experience in telephonic care management and skilled nursing facility care 
• Experience in kidney care and RAC-CT certification preferred. 
• Knowledge of value-based care models and strategies to reduce readmissions.
• Strong understanding of skilled nursing facility operations and regulations strongly preferred. 
• You have excellent working knowledge of community resources
• You can navigate ambiguity in an environment where full scope of information might not be available or might be delayed in coming
• You have experience in caring for people living with kidney disease, or a willingness to learn how to serve this unique population
• You have experience with team-based care and have excellent collaboration skills
• You have an exceptional capacity to multitask
• You are self-directed
• You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges
• Excellent communication, problem-solving and organizational skills. 
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• You have the ability to work effectively in a primarily remote environment:
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended
• Evergreen will provide Remote or Hybrid Home/Office employees with telephony applications and equipment to meet the business requirements for their position/job
• Team Members must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Compensation

The pay range for this role is $90,000 to $100,000 annually, exact pay determined based on experience, education, demand for role, geographic location, and other role-specific criteria. This role is also eligible for a bonus. 

How You’re Supported 

You will benefit from Evergreen Nephrology’s exceptional total rewards package, which includes: 

• Competitive base pay with bonuses 
• 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 
• 401(k) with match 
• Paid parental leave 
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology 

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.

If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.