Transition of Care Coordinator - Eastern Time Zone

Evergreen Nephrology, LLC.; Mississippi; On-site; Full time

Job summary

An innovative healthcare organization is seeking a dedicated Transition of Care Coordinator to enhance patient outcomes and support kidney care. This remote position focuses on patient engagement, care coordination, and addressing social determinants of health. You will collaborate with a multidisciplinary team to ensure seamless transitions of care and empower patients through education and resource navigation. Join a forward-thinking team committed to transforming kidney care and improving the lives of patients. If you are passionate about making a difference in healthcare, this role offers a rewarding opportunity to thrive in a dynamic environment.

Benefits

Paid time off starting at 4 weeks

12 paid holidays per year

Medical, dental, vision and life insurance

401(k) with match

Paid parental leave

Reimbursement for continuing medical education

Robust training and development program

Qualifications

• 3 years of experience in healthcare coordination or community health.
• Strong communication and teaching skills are essential.

Responsibilities

• Coordinate patient care and ensure exceptional service.
• Advocate for patients and connect them to necessary resources.

Skills

Health Care Coordination

Community Health Work

Communication Skills

Problem Solving

Prioritization

Teaching Skills

Education

3+ years in healthcare coordination or related field

Tools

MS Office Suite

Telephony Applications

Job description

Transition of Care Coordinator - Eastern Time Zone

Remote

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.

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.

This will be a remote position that will support Eastern Time Zone.

Your Role

You are responsible for influencing and ensuring the best clinical care for patients through exceptional patient service and care coordination across disciplines. Leveraging an integrated technology platform, you are complemented by an entire interdisciplinary team including Nurse Practitioners, Nurse Care Managers, Dieticians, Pharmacists, Licensed Clinical Social Workers, Population Health Social Workers and Psychiatrists.

You will take the lead on comprehensive care coordination with a focus on identifying and addressing Social Determinants of Health while partnering with the interdisciplinary care team. You will be an essential resource for patients, assisting them in navigating the healthcare system, accessing resources and support, and achieving better health outcomes.

Primary Functions

1. Patient Engagement and Enrollment
   • 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.
2. Care Coordination
   • 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.
3. Social Determinants of Health
   • 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.
4. Resource Navigation
   • 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.
5. Member Advocacy
   • Advocate for members by identifying barriers to care, ensuring they receive appropriate support and interventions, and working to address inequities in health access.
6. 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.
7. Documentation and Reporting
   • Ensure accurate and timely documentation of member interactions, assessments, and care plans in accordance with organizational policies and regulatory requirements.
8. Education and Empowerment
   • 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.
9. Other duties as assigned, including cross coverage between markets, when needed.

Required Qualifications

1. You reviewed the Who You Are section of this job posting and immediately felt the need to read that makes you a match for our innovative culture.
2. You accept that things change quickly in a start-up environment and are willing to pivot rapidly on priorities.
3. 3 years of experience in health care coordination, community health work, or similar healthcare related field.
4. Experience with team-based approach to care.
5. Excellent working knowledge of community resources.
6. Exceptional ability to prioritize and task-switch to meet needs of patients and overall care team.
7. Self-directed and motivated to resolve issues professionally and creatively.
8. Strong communication and teaching skills.
9. Intermediate skills with MS Office Suite of products including Outlook and Teams.
10. 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 $19.00 per hour to $23.00 per hour. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors. 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.