Job Description

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 support programs.
• Resource Navigation
  • Guide members in understanding and utilizing health and social services, both within Evergreen Nephrology and with other providers and community-based organizations, to improve access to care and enhance their overall well-being.
• Member Advocacy
  • Advocate for members by identifying barriers to care, ensuring they receive appropriate support and interventions, and working to address inequities in health access and outcomes.
• Collaborative Communication
  • Maintain open lines of communication with patients and their families, caregivers, and healthcare teams to ensure coordinated care and support patients through any issues that may arise during the care process.
• Documentation and Reporting
  • Ensure accurate and timely documentation of member interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements.
• Education and Empowerment
  • Identify and alleviate stressors and other barriers to quality care through providing educational resources and solutions to patients and their families with the aim of empowering patients to navigate their conditions with comprehensive support.
• Other duties as assigned, including cross coverage between markets, when needed.

Required Qualifications

• 3 years of experience in health care coordination, community health work, or similar healthcare related field
• Experience with team-based approach to care
• Excellent working knowledge of community resources
• Exceptional ability to prioritize and task-switch to meet needs of patients and overall care team
• Self-directed and motivated to resolve issues professionally and creatively
• Strong communication and teaching 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

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