Nurse Care Manager – Transitions of Care (Remote) at Evergreen Nephrology | Improve Kidney Care Outcomes
Healthcare organizations are increasingly investing in value-based care models that improve patient outcomes while reducing unnecessary hospital readmissions. One of the most important roles in this transformation is the Nurse Care Manager, who helps patients transition safely from hospital to home while coordinating high-quality, patient-centered care.
Evergreen Nephrology is hiring a Nurse Care Manager – Transitions of Care for a full-time remote position. This opportunity is ideal for experienced Registered Nurses (RNs) with a background in care management, chronic disease management, and transitions of care who want to make a meaningful impact on the lives of patients living with kidney disease.
About Evergreen Nephrology
Evergreen Nephrology is a healthcare organization dedicated to transforming kidney care through a comprehensive, value-based approach. The company partners with nephrologists across the United States to deliver coordinated, person-centered care that helps delay kidney disease progression, reduce hospitalizations, support home-based care, and improve access to kidney transplants.
Its interdisciplinary care model brings together physicians, advanced practice providers, nurses, dietitians, social workers, and care coordinators to address the medical, emotional, and social needs of every patient.
About the Role
As a Transitions of Care Nurse Care Manager, you will manage a panel of patients recently discharged from the hospital and help them navigate the next stage of their healthcare journey.
Working remotely, you'll collaborate with physicians, Advanced Practice Providers (APPs), and interdisciplinary care teams to ensure patients receive timely follow-up care, medication management, education, and community resources that support successful recovery.
This position follows Central Time business hours (8:30 a.m. – 5:00 p.m.) despite being fully remote.
Key Responsibilities
Coordinate Transitional Care
You'll guide patients as they move from hospital care back to their homes or community by:
- Managing assigned patient panels.
- Coordinating follow-up appointments.
- Monitoring patient progress.
- Addressing barriers to recovery.
- Supporting continuity of care.
Develop Personalized Care Plans
Responsibilities include:
- Performing comprehensive patient assessments.
- Identifying medical and social needs.
- Evaluating social determinants of health.
- Creating individualized care plans.
- Updating care strategies as patient needs change.
Collaborate with Clinical Teams
You'll work closely with:
- Nephrologists.
- Primary care providers.
- Advanced Practice Providers.
- Care coordinators.
- Community healthcare partners.
- Patients and caregivers.
Strong interdisciplinary collaboration is central to Evergreen's care model.
Educate Patients and Families
The role includes:
- Explaining treatment plans.
- Supporting medication reconciliation.
- Encouraging treatment adherence.
- Providing disease education.
- Helping patients make informed healthcare decisions.
Improve Patient Outcomes
You'll also:
- Reduce avoidable hospital readmissions.
- Monitor care plan effectiveness.
- Participate in clinical meetings.
- Track patient outcomes.
- Support quality improvement initiatives.
Your work directly contributes to improved patient health and better value-based care performance.
Required Qualifications
Qualified applicants should generally have:
- Associate Degree in Nursing (or higher).
- Active Registered Nurse (RN) license.
- Compact RN License preferred.
- Minimum 3 years of care management experience.
- At least 2 years of Transitions of Care experience.
- Experience managing chronic and complex medical conditions.
- Utilization management experience.
- Strong communication and collaboration skills.
- Intermediate proficiency with Microsoft Outlook and Teams.
Preferred Skills
Candidates with the following experience may have an advantage:
- Kidney disease management.
- Value-based care.
- Case management.
- Population health.
- Chronic disease management.
- Patient advocacy.
- Care coordination.
- Community resource navigation.
Certified Case Manager (CCM) credentials may also strengthen an application.
Salary and Benefits
Evergreen Nephrology offers a competitive compensation package that includes:
- Annual salary of $90,000–$103,000 USD.
- Quarterly performance bonus.
- Fully remote work.
- Medical, dental, and vision insurance.
- 401(k) with employer matching.
- Generous paid time off.
- Paid company holidays.
- Parental leave benefits.
- Professional development opportunities.
Career Growth Opportunities
Professionals who excel in this role may advance into positions such as:
- Senior Nurse Care Manager.
- Clinical Program Manager.
- Director of Care Management.
- Population Health Manager.
- Clinical Operations Leader.
- Value-Based Care Director.
Demand for experienced care management professionals continues to grow as healthcare organizations expand value-based care programs.
Why This Opportunity Stands Out
Evergreen Nephrology is committed to improving healthcare outcomes for people living with kidney disease through compassionate, coordinated, and evidence-based care.
Joining the organization allows you to:
- Work remotely while serving patients nationwide.
- Build meaningful relationships with patients and families.
- Collaborate with multidisciplinary healthcare professionals.
- Influence long-term patient outcomes.
- Contribute to innovative value-based healthcare delivery.
- Grow your nursing leadership career within a mission-driven organization.
For experienced Registered Nurses passionate about care coordination and chronic disease management, this role offers both professional fulfillment and long-term career development.
How to Apply
Interested candidates can submit their application through Evergreen Nephrology's official careers portal.
Application Link:
Applicants should prepare an updated resume highlighting experience in care management, transitions of care, chronic disease management, patient education, interdisciplinary collaboration, and value-based healthcare. Demonstrating measurable improvements in patient outcomes or care coordination will strengthen your application.
Final Thoughts
The Nurse Care Manager – Transitions of Care role at Evergreen Nephrology is an excellent opportunity for experienced Registered Nurses who want to improve the lives of patients with kidney disease while advancing their careers in value-based healthcare.
From coordinating post-hospital care and developing personalized care plans to collaborating with multidisciplinary teams and improving patient outcomes, this remote position offers meaningful work, competitive compensation, and excellent opportunities for professional growth.
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