Care Coordinator, LPN (Bilingual)

Evergreen Nephrology, LLC.; United States; Remote; USD 55,000 - 65,000; Full time

Benefits offered by this job

4 weeks PTO

12 paid holidays

Health insurance

HSA with employer match

CME reimbursement

401(k) match

Paid parental leave

Robust training program

Job summary

Evergreen Nephrology is seeking a licensed practical nurse (LPN) for a fully remote role aligned to Pacific Time hours (8:30am–5pm). Responsibilities include monthly CCM check-ins, care-plan reinforcement, and accurate documentation across EHR and CCM platforms.

Strong clinical judgment, two-system proficiency, and a California LPN license are required. The role offers a competitive pay range of $55,000–$65,000 annually, plus a quarterly bonus and a comprehensive benefits package including PTO,

Qualifications

• Active California LPN or LVN license.
• 1–2 years in ambulatory care, population health, care coordination or case management.

Responsibilities

• Conduct monthly CCM check-ins and address clinical concerns.
• Reinforce care plans and support adherence to medications and lifestyle changes.
• Document interactions clearly in EHR and CCM platform.
• Escalate urgent issues per triage pathways and coordinate with providers.

Skills

Clinical assessment

Communication

Documentation

Remote work

MS Office

Education

LPN/LVn license

Tools

EHR

CCM platform

Job description

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 do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. 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.

Who You Are

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. 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 thrive in innovative and evolving environments with high rates of change.

Your Role

As a Licensed Practical Nurse (LPN) with Evergreen Nephrology, you are responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns, reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy across both the EHR and partner technology platform. This position requires clinical judgment, licensed expertise, and the ability to support patients between office visits while collaborating closely with Evergreen’s providers, care teams, and leadership. LPNs are essential to delivering a safe, compliant, clinically credible Connected Care Program.

The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.

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

Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Perform monthly CCM touchpoints for assigned patient panels.
• Build strong, ongoing relationships with patients and caregivers through regular outreach.
• Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls.
• Explain CCM participation and reinforce program benefits.
• Clinical Assessments & Judgment
  • Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.).
  • Evaluate changes in condition using licensed clinical judgment.
  • Assess medication adherence issues, side effects, or confusion about regimen.
  • Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals).
• Escalate urgent issues based on defined triage pathways (same-business-day or immediate).
• Collaborate with the provider team on symptom changes, new concerns, or medication-related issues.
  • Route EHR messages with clinically relevant documentation.
  • Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care.
• Care Plan Reinforcement & Patient Education
  • Reinforce provider-developed CKD and chronic disease care plans.
  • Provide clinical explanation of symptom management instructions (within LPN scope).
  • Support adherence to medications, lifestyle changes, and follow-up instructions.
  • Identify social, behavioral, or access barriers and determine appropriate interventions or referrals.
• Documentation, EHR Updates & Compliance
  • Document all patient interactions clearly in both the EHR and CCM patient management platform.
  • Track and log qualifying CCM time accurately for billing compliance.
  • Ensure documentation meets regulatory, internal QA, and partner expectations.
  • Maintain high call quality and adherence to scripting and workflow pathways.
• Quality, Performance & Continuous Improvement
  • Maintain or exceed:
    • ≥80% monthly engagement
    • ≥90% billable conversion
    • High QA/documentation accuracy scores
  • Participate in peer reviews, QA audits, coaching sessions, and continuous education.
  • Identify recurring patient needs and communicate trends to the Program Manager.
• Other duties consistent with this role, as assigned.

Required Qualifications

• Active California LPN or Licensed Vocational Nurse (LVN) license
• Minimum 1–2 years of clinical experience in:
  • Ambulatory care
  • Population health
  • Care coordination
  • Case management
• Strong clinical assessment, communication, and documentation skills.
• Comfortable working in two systems (EHR + CCM platform) simultaneously.
• Ability to manage a structured, metric-driven workflow with reliability.
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote environment:
  • 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
  • Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Experience in chronic disease management
• Prior work in virtual care, remote nursing, or telehealth programs.
• Familiarity with CCM regulatory requirements.
• Strong patient education and motivational interviewing skills.

Compensation

The pay range for this role is $55,000-$65,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

This role is also eligible for a quarterly bonus.

Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:

• 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 for eligible roles
• A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
• 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 [e-mail] .

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 hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential 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.

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 measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis 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.