Nurse Care Manager Transitions of Care

About the Role

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. We are committed to improving patient outcomes and quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

Who You Are:

• Devoted and compassionate professional focused on front-line healthcare.
• Excited to build healthcare delivery models that ensure the highest quality of life for patients.
• Thrive in innovative and evolving environments with high rates of change.

Your Role:

As a Transitions of Care Nurse Care Manager, you are responsible for collaborating with a team of physicians, Advanced Practice Providers (APPs), and Interdisciplinary Team (IDT) members to manage an assigned patient panel. Key responsibilities include:

• Addressing specialized patient needs based on recent hospitalizations.
• Providing best-in-class interdisciplinary clinical resources and analytical tools.
• Pushing beyond the status quo of modern care management systems.
• Listening to and addressing the needs of patients and client partners.

Required Skills