Who You Are

You are looking for an entry-level position and are interested in working with a Nashville-based entrepreneurial firm focused on building and growing transformational companies. You have a strong desire to lend your project management and analytical skills to up-and-coming companies that will make a major impact in healthcare. You thrive in innovative and evolving environments with high rates of change. You are driven by process-improvements. Does this sound like you? If so, we should talk.

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 and 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.

Your Role

The Transition of Care (TOC) Coordinator as a valued member of our interdisciplinary team is responsible for supporting the development and execution on the transition plan of patients from the hospital or other facility to the home environment. The position will directly contribute to improving health outcomes, cost, and reducing likelihood of further hospitalization. This role establishes and builds relationships with community hospitals and post-acute providers including but not limited to discharge planners at hospital, nursing home, sub-acute rehabilitation, and behavioral health settings, primary care practices, specialists and home health agencies, in addition to our nephrology practice partners. The TOC Coordinator will help to proactively manage length of stay in any out-of-home setting by identifying current health status, progress toward goals, support for patient at home, and available community services.

Primary functions for the Transition of Care Coordinator:

• Develops and maintains strong relationships, partnerships, and collaborations with new and established hospitals, post-acute facilities, and community-based organizations.

• Collaborate with Evergreen health service leadership to ensure an aligned approach on relationship building with providers/organizations in the community.
• Provide strategic and focused community-facing education on the Evergreen model, nephrology practice enhancements, and wrap around supports to assist in decreasing unnecessary utilization of services.
• Promotes transition of care protocols and care management for high need members by bringing awareness of the value of timely post discharge visits to prevent rapid readmission and the case management model of care.

• Establishes connection and acts as the primary contact to high volume facilities to do rounding, both in person and via telephone.
• Escalates clinical issues and urgent needs to care team and provides daily updates on census to primary care provider and care management teams.
• Responsible for tracking and trending all aspects of the transition of care process and following up to ensure follow up appointments have successfully occurred.
• Documents all member encounters in the appropriate EHR and tracking grids.
• Utilize Health Information Exchange (HIE) information and alerts to support care delivery, notification of an out of home placement in ER, Inpatient Facility, Skilled Nursing/Rehab Facility. Alert EHR and care team, as appropriate.
• Other duties as assigned.

How You Qualify

• Associate degree in Nursing preferred, not required.
• Associate degree in Health Care, Human Services or a related field or equivalent work with two years' experience required.
• Experience in building relationships, community collaboration, and education preferred.
• Sales experience helpful, not required.

• Candidate must possess a valid driver's license and be willing and able to drive a car.
  • Local travel may be up to ~50% of time.
  • Must provide proof of current auto registration and insurance coverage.
• Ability to effectively communicate preventive health, health education, and health management philosophies to member cohort and agencies.
• Knowledge and understanding of medical terminology, direct contracting, and value-based care
• Strong computer skills: ability to run reports, merge data sets, sort.
• Ability to use computer-based programs: Office (Outlook, Word, Excel, PowerPoint), Internet searches, electronic health records.
• Ability to quickly establish a rapport with others.
• Extremely organized.
• Maintain HIPAA standards
• Other duties as assigned

How You are Supported

• You will benefit from Evergreen Nephrology's exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at 4 weeks for full time employees, 11 paid holidays per year, reimbursement for continuing medical education, 401k with match (coming soon), health, dental, and vision insurance
• Family friendly policies that support paid parental leave and flexible work arrangements.
• As a team member you'll be supported by our robust commitment to training and development that starts with onboarding and continues throughout your career with Evergreen Nephrology
• You will collaborate with like-minded healthcare professionals who, like you, understand the importance and value of Evergreen Nephrology's high-quality, value-based, care model

Evergreen Nephrology is an equal opportunity employer that is committed to inclusion and diversity. We take affirmative action to ensure equal opportunity for all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics. Learn more about your EEO rights as an applicant (Opens in a new window).

Evergreen Nephrology will not discriminate or retaliate against applicants who inquire about, disclose, or discuss their compensation or that of other applicants. United States Department of Labor. Learn more (Opens in a new window).

Evergreen Nephrology is committed to working with and providing reasonable accommodations to job applicants with physical or mental disabilities. Applicants with a disability who require a reasonable accommodation for any part of the application or hiring process should email hwasielewski-lopez@evergreennephrology.com for assistance. Reasonable accommodations will be determined on a case-by-case basis.