Back to jobs
New

MDS Nurse Care Manager - Post Acute Care (CST or MST)

Remote - All Locations

Who We Are 

Evergreen Nephrology partners with nephrologists and other providers to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe people living with kidney disease deserve the best care. We are committed to improving patient outcomes and quality of life by delaying disease progression, engaging patients in their own care, optimizing care delivery and transitions, and accelerating kidney transplants through partnerships with our nephrologists and other providers, best-in-class interdisciplinary clinical resources, and technology and analytics platform that enables optimized insights and care. 

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of people living with kidney disease. You’re 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. You are passionate about value-based care and understand its importance in improving outcomes and reducing health care costs. You thrive in innovative and evolving environments with high rates of change. 

Your Role 

As a Post Acute Nurse Care Manager, you are responsible for collaborating with Skilled Nursing Facilities to manage nephrology patients who are receiving skilled nursing care after an acute hospitalization. This role focuses on ensuring their skilled nursing stay promotes efficiency as well as meets their specialized needs based on their individual conditions with a coordinated plan to discharge to home or community. Your job duties will include taking full ownership of patient care management within your caseload, including engaging with Skilled Nursing Facility staff, providers, patients, and their caregivers. You will perform assessments to identify needs based on individual values, goals, and preferences.

Role Responsibilities

  • Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
  • Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community.
  • Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed.
  • Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge.
  • Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management.
  • Develop and implement strategies to optimize length of stay while maintaining high-quality care.
  • Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders.
  • Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
  • Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans.
  • Identify and develop SNF stakeholders and foster relationships for communication and coordination of care.
  • Identify areas for improvement in post-acute care processes and share or implement evidence-based solutions.
  • Engage in continuous, organizational process improvement to identify opportunities and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols.
  • Prepare reports and other deliverables to communicate program changes or developments to appropriate stakeholders
  • Collect data to prepare and deliver reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction.
  • Other duties consistent with this role, as assigned

Required Qualifications  

  • Associate degree in nursing required (ASN); bachelor’s degree in nursing (BSN) preferred.
  • Current RN License required; Compact License preferred.  
  • Minimum 3-5 years of experience in telephonic care management and skilled nursing facility care 
  • Experience in kidney care and RAC-CT certification preferred. 
  • Knowledge of value-based care models and strategies to reduce readmissions.
  • Strong understanding of skilled nursing facility operations and regulations strongly preferred. 
  • You have excellent working knowledge of community resources
  • You can navigate ambiguity in an environment where full scope of information might not be available or might be delayed in coming
  • You have experience in caring for people living with kidney disease, or a willingness to learn how to serve this unique population
  • You have experience with team-based care and have excellent collaboration skills
  • You have an exceptional capacity to multitask
  • You are self-directed
  • You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges
  • Excellent communication, problem-solving and organizational 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

Compensation

The pay range for this role is $90,000 to $100,000 annually, exact pay determined based on experience, education, demand for role, geographic location, and other role-specific criteria. This role is also eligible for a bonus. 

How You’re Supported 

You will benefit from Evergreen Nephrology’s exceptional total rewards package, which includes: 

  • Competitive base pay with bonuses 
  • 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 education 
  • 401(k) with match 
  • Paid parental leave 
  • 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 recruiting@evergreennephrology.com. 

Apply for this job

*

indicates a required field

Resume/CV*

Accepted file types: pdf, doc, docx, txt, rtf

Cover Letter

Accepted file types: pdf, doc, docx, txt, rtf

Select...
Select...
What time zones are you willing to support? Please note that for any time zones selected, you must be able to work from 8:30am – 5pm in that time zone: *
Select...
Select...
Select...
Select...

Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey. Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.

As set forth in Evergreen Nephrology’s Equal Employment Opportunity policy, we do not discriminate on the basis of any protected group status under any applicable law.

Select...
Select...
Race & Ethnicity Definitions

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection. As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categories is as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Select...

Voluntary Self-Identification of Disability

Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 04/30/2026

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury
Select...

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.