Nurse Navigator (RN)

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.

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 an Onsite 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, escalate 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
• Active, unrestricted Registered Nurse (RN) Illinois license
• 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