Compassionate Care Nurse Care Manager

Your Role

As an Evergreen Compassionate Care Nurse Care Manager with Evergreen Nephrology, you will work closely with the Program Manager of the Evergreen Compassionate Care Program (ECCP) to manage the healthcare journey of patients referred to the program based on their unique healthcare needs, goals, and wishes. You will collaborate with a team of Physicians, Advanced Practice Providers, and interdisciplinary team members to manage patients referred to the ECCP by taking full ownership of patients within your panel, focusing on helping patients with kidney disease understand their diagnosis and prognosis as well as services available to them so they are empowered to make healthcare decisions they are comfortable with.

You will perform assessments and advance care planning conversations to identify their needs based on their values, goals, and preferences. You will assess patients for hospice appropriateness and hospice-mindedness. From this assessment, you will either refer patients to the appropriate program within Evergreen for ongoing kidney care management with or without dialysis, and or will coordinate continued care under their nephrologist; or coordinate a transition to hospice care in collaboration with community providers. You will act as a clinical liaison and educator, working closely with the Program Manager of the ECCP, to provide resources and training both internally and externally regarding identifying patients who need advance care planning and goals or care discussions, and/or patients who may be appropriate for hospice care.

While this position is fully remote , you must be able to work 8:30am – 5pm in the Central time zone.

Role Responsibilities

• Quickly build empathetic relationships with patients and families.
• Effectively complete patient education (including family involvement as appropriate) regarding diagnosis, prognosis, treatment options, and advocate for access to the preferred treatment option.
• Evaluate and identify patient’s needs based on their respective values, goals, and preferences by completing advance care planning (ACP) including a Goals Of Care (GOC) discussion and then translate the needs into clinical needs.
• Apply critical thinking skills to the analysis of the data collected.
• Identify opportunities for improvement in palliation of symptoms and develop a plan of care collaboratively with the patient’s providers.
• Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources.
• Actively participate in huddles, IDT sessions, and patient case conferences as appropriate.
• Interface with Nephrology Partners, Primary Care Physicians, Advanced Practice Providers, Specialists, and various disciplines on the development of case management plans/programs.
• Develop the plan of care with input from the patient/family, as a result of the goals of care discussion(s), and the interdisciplinary team.
• Ensure that accurate records are maintained of the care associated with each patient.
• Communicate and implement the plan of care in all settings, including with community palliative care and hospice providers.
• Coordinating care and access to health services across multiple providers/disciplines (home health, palliative care, hospice, pastoral care and counseling, etc).
• Evaluate the ongoing progress toward appropriate outcomes and care transitions.
• Reassess and revise the plan of care as needed in collaboration with patient/family through ongoing goals of care discussions, and input from the interdisciplinary team, and document appropriately.
• Required to maintain current knowledge and competency of hospice and palliative care nursing.
• Educate internal partners, and external partners in the community, about the ECCP and how to identify and refer patients to the program.
• Commendably represent Evergreen to patients, their families, and the community.
• Other duties consistent with this role, as assigned.

Required Qualifications

• Active RN license in good standing
• 3+ years of clinical practice in an intensive care unit, or a hospice or palliative care role
• Experience having goals of care discussions and discussions regarding end-of-life care decisions required
• Able to pivot quickly on priorities in a quickly changing startup environment
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• You have the ability to work effectively in a 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

Preferred Qualifications

• CHPN (Certified Hospice and Palliative Care Nurse)
• Compact RN licensure
• BSN
• 1+ years of utilization management experience