Care Coordinator - CKD Navigation

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. 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 thrive in innovative and evolving environments with high rates of change.

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

You are responsible for influencing and ensuring the best clinical care for patients through exceptional patient service and care coordination across disciplines. Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Dieticians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers and Psychiatrists. You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

Primary Functions

• Patient Engagement and Enrollment
  • Perform telephonic outreach to enroll and engage patients identified for your clinical program and establish connection as primary point of contact for enrolled patients in the program.
• Care Coordination
  • Under the direction of your Nurse Care Manager (NCM), develop and implement care plans addressing the unique needs of patients, ensuring collaborative and cohesive support across and throughout the patient’s healthcare journey.
  • Facilitate seamless transitions of care through collaborative pathways across care settings and dialysis centers to ensure strong social support and comprehensive care plans.
  • Update established patient care plans, as appropriate, to drive enhanced care delivery and coordination.
• Social Determinants of Health
  • In collaboration with your NCM, conduct thorough patient assessments to identify social, economic, and environmental factors impacting members' health, with the goal of recommending gap closures to improve quality and health outcomes for inclusion in the comprehensive care plan.
  • Connect members to appropriate resources such as housing assistance, transportation, food security, and community services.