Full-time Registered Nurse in Home Health Care

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. Youre 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. 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 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.
This is a hybrid position that will work remotely and at our practice partner offices Renal Care Associates (RCA) and assigned hospitals in the Peoria IL area.
As an Onsite Nurse Navigator you will serve as RCAs clinical presence within assigned hospitals and help manage the transition from hospitalization through a safe return home or successful placement in a post-acute setting (Skilled Nursing Facility). You will identify RCAs patients aligned to Evergreen Nephrology early in the hospitalization engage patients and caregivers at the bedside collaborate with hospital care teams on discharge readiness and help close gaps that contribute to an avoidable readmission or prolonged post-acute stay.
This Nurse Navigator owns the closed loop transition plan in collaboration with the patients nephrologist and or other specialist or PCPs that are part of the patients care team as well as Evergreen Care Management teams. This is a transitional position and does not provide longitudinal care after handoff except for following appropriate patients discharged to SNF. This role requires an RN who is comfortable collaborating across care settings influencing discharge planning decisions and building trusted relationships with hospital teams post-acute providers patients and families. This person must be energized by innovation value-based care and opportunities to improve healthcare delivery.

Identify RCA/EG patients during inpatient admissions through hospital census review referrals EG ADT feeds
Identify patients who may be able to safely transition home or with home health instead of entering a post-acute facility and work with the patient caregiver and hospital team to address the barriers that could prevent that discharge plan while respecting patient choice.
Conduct bedside patient assessments to evaluate clinical psychosocial caregiver and discharge planning needs.
Collaborate with physicians case managers social workers utilization management teams discharge planners and other interdisciplinary team members to support safe transitions home or to post-acute care facility
Promote home-based care and home health services whenever clinically appropriate.
For patients discharged to a SNF maintain short-term transition follow-up to confirm the discharge plan and target date identify stalled progress escalate changes in condition support return-home planning and complete the handoff to EG CM when indicated. Support medication reconciliation identify med related risk/ barriers and confirm the patient understands the discharge medication plan.
Assess social determinants of health and identify barriers that may increase risk for readmission or poor outcomes.
Work with hospital case management to ensure required nephrology primary care and specialty follow-up is scheduled and clearly handed off before discharge.
Confirm that the immediate post-discharge plan is in place including medications home health services DME transportation FU appointments and handoff to EG CM as appropriate. Support enrollment in Evergreen care management and clinical programs through effective warm handoffs and transition planning.
Follow patients through post-acute settings including skilled nursing facilities to ensure continuity of care.
Participate in interdisciplinary rounds care conferences and discharge planning meetings.
Collect and report program metrics patient outcomes and utilization data.
Support process improvement initiatives designed to enhance care transitions reduce readmissions and optimize post-acute outcomes.
Build and maintain strong relationships with hospital leadership care coordination departments nephrology practices and community partners.
Active unrestricted Registered Nurse (RN) Illinois license
Bachelor of Science in Nursing (BSN) preferred
Minimum of 3-5 years of clinical nursing experience
Hospital Case Management
Care Coordination
Hospital Nursing
Transitional Care Management
Population Health
Nephrology
Home Health
Post-Acute Care
Strong understanding of acute care discharge planning processes
Ability to travel locally between assigned facilities based on program and patient needs
Experience collaborating with interdisciplinary care teams
Excellent communication relationship-building and patient education skills
Intermediate proficiency with Microsoft Office Suite including Outlook and Teams
Ability to work independently and effectively in a hospital-based environment while remaining closely connected to Evergreen
Ability to obtain and maintain hospital credentialing badging and required health clearances
Comfort working with hospital census referral and patient-identification workflows
Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable Fiber or DSL connections hardwired to the internet device are recommended
Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
This role is also eligible for a quarterly bonus.
Paid time off starting at 4 weeks for full-time employees

• 12 paid holidays per year
• Medical dental vision and life insurance including an HSA with employer match
• Reimbursement for continuing medical educationfor eligible roles
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race color creed sex sexual orientation gender identity or expression age religion national origin citizenship status disability ancestry marital status veteran status medical condition or any other protected category under local state or federal laws.
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process please contact us for assistance at .