Care Coordinator

Description:

Evergreen Nephrology is seeking a Care Coordinator to join their team in providing holistic, patient-centered care for individuals with chronic kidney disease (CKD). This fully remote role is focused on supporting patients across the Mountain and Central Time Zones, helping them navigate the healthcare system and access resources to improve their health outcomes and quality of life.

The Care Coordinator will serve as the primary point of contact for enrolled patients, working closely with an interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Dieticians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers, and Psychiatrists. Key responsibilities include:

• Patient Engagement and Enrollment: Conduct telephonic outreach to enroll and engage patients, establishing strong patient relationships and acting as their main point of contact.

• Care Coordination: Develop and implement individualized care plans under the direction of a Nurse Care Manager, facilitating seamless transitions across care settings and dialysis centers.

• Social Determinants of Health: Identify and address social, economic, and environmental factors impacting patients’ health, connecting them to community resources such as housing, transportation, and food security.

• Resource Navigation: Guide patients in accessing healthcare and social services to enhance overall well-being.

• Member Advocacy: Advocate for patients by removing barriers to care and addressing inequities in health access and outcomes.

• Collaborative Communication: Maintain open communication with patients, families, caregivers, and healthcare teams to ensure coordinated care.

• Documentation and Reporting: Ensure timely and accurate documentation of all patient interactions and care plans.

• Education and Empowerment: Provide educational resources to empower patients in managing their condition effectively.

• Other Duties: Provide cross-coverage between markets as needed.

Required Qualifications:

• 3+ years of experience in healthcare coordination, community health, or related field

• Team-based care experience

• Strong knowledge of community resources

• Excellent prioritization, multitasking, and problem-solving skills

• Strong communication and teaching abilities

• Intermediate skills in MS Office Suite (Outlook, Teams)

• Ability to work effectively in a remote environment with appropriate internet connectivity

Compensation & Benefits:

• Hourly pay: $19 - $23 per hour (based on experience)

• Eligible for bonus

• Paid time off (starting at 4 weeks for full-time employees) and 12 paid holidays

• Medical, dental, vision, life insurance, and HSA with employer match

• 401(k) with match

• Paid parental leave

• Continuing medical education reimbursement

• Robust ongoing training and professional development

About the Organization:
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. They focus on delaying disease progression, shifting care to the home, and accelerating kidney transplants, supporting both patients and providers with top-tier interdisciplinary clinical resources and analytical tools.