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Care Coordinator

4 months ago

Nashville, United States Evergreen Nephrology Full time
WHO YOU ARE

You are devoted and compassionate, and enjoy being on the front lines of healthcare, changing the lives of your patients. You're passionate about digging in to get to the root cause of a patient's conditions, remove social determinants of healthcare, and ensure the highest possible quality of life and best outcomes for those in your care. You believe patients living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You don't want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your team and patients that you would to your own family member. You thrive in innovative and evolving environments with high rates of change. Process improvements drive you. Does this sound like you? If so, we should talk.

WHO WE ARE

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

We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients.

We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.

YOUR ROLE

As a Care Coordinator with Evergreen Nephrology, you will be responsible for a panel of patients and, in collaboration with other members of our Nephrology partners and interdisciplinary care team, help patients meet their kidney care and overall care goals. Care coordinators monitor and coordinate patients' treatment plans, educate them about their condition, connect them with health care providers, coordinate care with care centers and partners, and evaluate their progress.

PRIMARY FUNCTIONS
  • Establish trusting, supportive, collaborative relationships with patients and their families
  • Build relationships with patients in a clinical setting, working alongside the interdisciplinary team professionals, including nephrologists, nurse care managers, advanced practice providers, behavioral health advanced practice providers, pharmacists, social workers, and dietitians. Actively engage a panel of adult patients
  • Consistently track census on inpatient and skilled nursing facility admissions, coordinate care, ensure the proper discharge, and timely follow-up as appropriate
  • Closely work with NCMs on outpatient, longitudinal care coordination of in-home and community-based services, including but not limited to DME, home health, referrals, and in-home supportive services
  • Take responsibility (in partnership with providers and NCM) for the health of a population of patients and monitor and track whether those patients are up to date on preventive measures
  • Communicate with patients by phone or in person and escalate to the care team when necessary. Link patients to community resources
  • Assist with the coordination of care across the kidney care continuum, such as scheduling appointments with specialists and dialysis centers, coordinating referrals, and sharing or transferring information with the patient's internal and external care team
  • Participate in establishing a pragmatic care plan
  • Capture relevant information about the patient's health and healthcare experience, take vitals, administer point-of-care testing, and perform standard age and condition-appropriate screening assessments as needed
  • Other duties as assigned
YOU'RE GOOD AT
  • You reviewed the Who You Are section of this job posting and immediately felt the need to read on, which makes you a match for our innovative culture
  • You accept that things change quickly in a startup environment and are willing to pivot quickly on priorities
  • Experience in a team-based service environment
  • Interpersonal communication skills with exceptional listening abilities
  • Compassionate, kind, and open-minded
  • Excellent written and verbal communication skills
  • Some clinical experience is a plus, such as EMT, MA, CNA, or Phlebotomy certification
WE'RE GOOD AT
  • You will benefit from Evergreen Nephrology's exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at four weeks for full-time employees, 12 paid holidays per year, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance.
  • We are proud to offer family-friendly policies that support paid parental leave and flexible work arrangements.
  • We commit to a robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
  • As an inclusive and diverse team, you will collaborate with like-minded healthcare professionals who, like you, understand the importance and value of Evergreen Nephrology's high-quality, value-based care model