Nurse Navigator (RN)

Evergreen Nephrology, LLC.; Peoria (IL); Hybrid; USD 90,000 - 105,000; Full time

Benefits offered by this job

Paid time off 4 weeks

12 paid holidays

Medical, dental, vision, life + HSA

CME reimbursement

401(k) with 4% match

Parental leave

Training and development

Job summary

Evergreen Nephrology, LLC seeks an Onsite Nurse Navigator to support RCA hospitals in the Peoria area. You will coordinate transitions from hospitalization to home or post-acute care, engaging patients and families and collaborating with nephrology teams for timely discharges.

The role requires an RN with 3–5 years of clinical nursing experience; BSN preferred. Travel to local facilities and a collaborative, hybrid work environment are involved.

Qualifications

• BSN preferred and RN licensure required.
• Minimum 3–5 years of clinical nursing experience.
• Experience in hospital case management, care coordination, or transitional care.

Responsibilities

• Identify eligible patients during hospitalization for transition planning.
• Collaborate with hospital care teams to ensure safe discharge and follow-up.
• Build relationships with patients, families, and care partners.
• Coordinate transitions to home health or post-acute facilities.
• Support medication reconciliation and discharge planning.
• Maintain documentation and report program metrics.

Skills

RN License

Nurse Navigator

Discharge planning

Care coordination

Interdisciplinary collaboration

Patient education

Travel locally

Hospital care coordination

Education

Bachelor of Science in Nursing (BSN)

RN licensure

Tools

Microsoft Office

Job description

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.

Who We Are

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.

Location

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.

Your Role

As anOnsite Nurse Navigator, you will serve as RCA’s 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 RCA’s 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 patient's 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.

Role Responsibilities

Some responsibilities may vary based on program needs, but primary duties include:

• 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.
• Build trusted relationships with patients and caregivers and provide ongoing education and support throughout hospitalization.
• 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, elevate 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.
• Maintain timely and accurate documentation within designated systems.
• 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.
• Other duties consistent with this role, as assigned.

Required Qualifications

• Bachelor of Science in Nursing (BSN) preferred
• Minimum of 3-5 years of clinical nursing experience
• Experience in one or more of the following:
  • 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
• Strong critical thinking, problem-solving, and organizational abilities
• 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
• Able to work effectively in a hybrid 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

Compensation

The pay range for this role is $90,000 to $105,000 annually. Exact pay isdeterminedbased 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 educationfor eligible roles
• A401(k)program whereEvergreen 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.