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Evergreen Nephrology · 13 hours ago

Care Coordinator - CKD Navigation

United States

Full-time

Remote

Mid Level

$19/hr - $23/hr

3+ years exp

Evergreen Nephrology is committed to transforming kidney care through a person-centered approach. The Care Coordinator - CKD Navigation is responsible for ensuring exceptional patient service and care coordination, guiding patients through the healthcare system, and addressing Social Determinants of Health to improve health outcomes.

Health CareMedicalWellness

Responsibilities

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

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

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

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

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

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

Ensure accurate and timely documentation of member interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements

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

Qualification

Healthcare coordinationCommunity resources knowledgeCare plan developmentTeam-based care approachMS Office SuiteCommunication skillsPatient advocacyEducationEmpowermentProblem-solving

Required

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