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Patient Care Facilitator
2 months ago
You are dedicated and empathetic, thriving in the healthcare sector where you make a significant impact on patients' lives. Your commitment lies in uncovering the underlying causes of health issues, addressing social determinants of health, and ensuring optimal quality of life and outcomes for those you serve. You believe that individuals with kidney disease deserve exceptional, patient-centered, holistic care and are eager to influence the healthcare landscape towards this goal. You prioritize quality over quantity, providing the same level of care and dedication to your patients and team as you would to your own family. You excel in dynamic and rapidly changing environments, driven by a passion for process enhancement. Does this resonate with you? If so, we should connect.
WHO WE ARE
Evergreen Nephrology collaborates with nephrologists to revolutionize kidney care through a value-driven, patient-centered, holistic approach. We are committed to enhancing patient outcomes and improving quality of life by delaying disease progression, facilitating home care, and expediting kidney transplants.
We empower nephrologists to focus on the right patients at the right time throughout the entire care continuum by providing top-tier interdisciplinary clinical resources, analytical insights, and patient services.
We actively listen to the needs of our patients, employees, and partners, continuously striving to surpass the current standards of patient management in the healthcare system.
YOUR ROLE
As a Care Coordinator at Evergreen Nephrology, you will oversee a panel of patients and, in collaboration with our nephrology partners and interdisciplinary care team, assist patients in achieving their kidney care and overall health objectives. Care coordinators are responsible for monitoring and managing patients' treatment plans, educating them about their conditions, connecting them with healthcare providers, coordinating care with various centers and partners, and assessing their progress.
PRIMARY FUNCTIONS
- Establish and nurture trusting, supportive, and collaborative relationships with patients and their families.
- Engage with patients in a clinical environment, working alongside interdisciplinary team members, including nephrologists, nurse care managers, advanced practice providers, behavioral health specialists, pharmacists, social workers, and dietitians.
- Monitor census data on inpatient and skilled nursing facility admissions, coordinate care, ensure proper discharge, and facilitate timely follow-up as necessary.
- Collaborate closely with Nurse Care Managers on outpatient, longitudinal care coordination of in-home and community-based services, including DME, home health, referrals, and in-home support.
- Take responsibility, in partnership with providers and Nurse Care Managers, for the health of a patient population and track their adherence to preventive measures.
- Communicate with patients via phone or in person and escalate issues to the care team when needed. Connect patients with community resources.
- Assist in coordinating care across the kidney care continuum, including scheduling appointments with specialists and dialysis centers, managing referrals, and sharing or transferring information with the patient's internal and external care teams.
- Participate in developing a pragmatic care plan.
- Gather relevant information about the patient's health and healthcare experience, take vital signs, conduct point-of-care testing, and perform standard age and condition-appropriate screening assessments as required.
- Other duties as assigned.
- You resonated with the Who You Are section of this job posting, indicating a fit for our innovative culture.
- You understand that rapid changes are part of a startup environment and are adaptable to shifting priorities.
- Experience in a team-oriented service environment.
- Strong interpersonal communication skills with exceptional listening abilities.
- Compassionate, kind, and open-minded approach.
- Excellent written and verbal communication skills.
- Some clinical experience is advantageous, such as EMT, MA, CNA, or Phlebotomy certification.
- Evergreen Nephrology offers an exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at four weeks for full-time employees, 12 paid holidays annually, reimbursement for continuing medical education, a 401k with matching contributions, and health, dental, and vision insurance.
- We proudly provide family-friendly policies that support paid parental leave and flexible work arrangements.
- We are committed to a comprehensive training and development program that begins 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 understand the significance and value of Evergreen Nephrology's high-quality, value-based care model.
