Program Manager - Chronic and Complex Care Management & Transitions of Care

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. The Program Manager will lead a team focused on delivering patient-centered care for individuals with chronic conditions, ensuring high-quality care and improving patient outcomes.

Responsibilities:

• Oversee day-to-day operations for the CCPM and TOC care management teams, ensuring efficient workflows, standardized processes, and consistent achievement of program goals
• Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care, including adherence to clinical pathways, protocols, and documentation standards
• Continuously evaluate and improve the performance of CCPM and TOC programs and team members, consistent with Evergreen’s performance management philosophy
• Develop and implement collaborative strategies to improve program performance and patient outcomes (e.g., chronic disease control, complication prevention, and reduced readmissions) while ensuring patient and provider partner satisfaction
• Support newly hired CCPM/TOC team members through orientation and onboarding; provide ongoing training, coaching, and development for established team members
• Perform regular call and documentation (chart) audits to support performance management and identify opportunities for continuous improvement
• Prepare performance reports, dashboards (as applicable), and meeting materials for CCPM and TOC programs for internal and external audiences
• Oversee TOC workflows that support timely post-discharge outreach, medication reconciliation support, follow-up appointment coordination, and issue escalation to reduce avoidable readmissions
• Develop and foster relationships with key stakeholders (e.g., IDT members, market leaders, and other program leaders) to drive outcomes through collaboration and cross-program partnership across CCPM and TOC
• Build and maintain effective communication strategies between Evergreen and market stakeholders to foster strong relationships that support improved patient outcomes, in collaboration with market leaders
• Be a Culture Champion by cultivating a culture of high performance, transparency, trust, and collaboration
• Other duties consistent with this role, as assigned

Requirements:

• Bachelor's degree in healthcare or nursing (BSN required)
• Active state nursing license in good standing
• 3+ years of longitudinal clinical nursing care management experience required
• 2+ years of experience in a clinical nursing managerial or leadership role
• Experience in longitudinal care management
• Strong business acumen of value-based healthcare operations in disease management and population health programs
• Understanding of Business Continuity and how to build resiliency into business processes / systems
• Ability to develop talent, know when to delegate, innovate and iterate with your team, leveraging their strengths
• Exceptional relationship-building, communication, and change management skills, with the ability to influence effectively and establish trust and credibility quickly with internal and external partners
• Strong leadership presence which inspires others and instills confidence in peers, external partners, board members, and team members
• Execution-focused and hands-on, with the ability to effectively balance strategic priorities and detailed, day-to-day operational work (“in the weeds”)
• Able to motivate staff; influence people and outcomes, you promote team building
• Demonstrated ability to work effectively independently and as part of a team, in collaborative settings
• Commitment to maintaining highest level of confidentiality
• Organizational skills, operational rigor, resilience, and commitment to the business
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• Able to work effectively in a primarily remote 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
• Master's Degree in Nursing or Healthcare Administration or related field
• Experience with quality improvement using data to track and improve program performance
• Previous experience working within a managed care environment especially with experience in administrative/management capacity
• Experience in leading the clinical function of a Value Based Care organization