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Care Coordinator

Evergreen Nephrology

Evergreen Nephrology

Customer Service
Dover, DE, USA
Posted on Thursday, June 27, 2024


You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of your patients. You’re passionate about digging in to get to the root cause of a patient’s conditions, remove social determinants of healthcare, and ensure the highest possible quality of life and best outcomes for those in your care. You believe patients living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You don’t want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your team and patients that you would to your own family member. 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.


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.


As a Care Coordinator with Evergreen Nephrology, you will be collaborating with other members of our Nephrology partners and interdisciplinary care team to help patients meet their kidney care and overall care goals. Care coordinators monitor the care coordination of patients' treatment plans, educate them about necessary care coordination as it relates to their conditions, connect them with healthcare providers, and coordinate care with care centers. As a Care Coordinator, you will also help us identify and memorialize best practices and onboard your peer Care Coordinators.


  • Establish trusting, supportive, and collaborative relationships with patients and their families
  • Build relationships with patients in a clinical setting, working alongside interdisciplinary team professionals, including nephrologists, nurse care managers, advanced practice providers, behavioral health advanced practice providers, pharmacists, social workers, and dietitians; Actively engage a panel of adult patients
  • Consistently track census on inpatient and skilled nursing facility admissions, coordinate care, ensure the proper discharge, and follow up as appropriate in a timely manner
  • Closely work with NCMs on outpatient, longitudinal care coordination of in-home and community-based services, including but not limited to DME, home health, referrals, and in-home supportive services
  • Take responsibility (in partnership with the IDT team) for the health of a population of patients and monitor and track whether those patients are up to date on preventive measures
  • Communicate with patients by phone or in person and escalate to the care team when necessary; Link patients to community resources
  • Assist with the coordination of care across the kidney care continuum, such as scheduling appointments with specialist and dialysis centers, coordinating referrals, and sharing or transferring information with the patient’s internal and external care team
  • Participate in establishing a pragmatic care plan
  • Capture relevant information about the patient’s health and healthcare experience
  • Create and maintain the care coordinator playbook
  • Mentor and support onboarding of other care coordinators
  • Participate in quality and process improvement projects
  • Other duties as assigned


  • You reviewed the Who You Are section of this job posting and immediately felt the need to read on, which makes you a match for our innovative culture
  • You accept that things change quickly in a startup environment and are willing to pivot quickly on priorities
  • 2+ years in a healthcare-related care coordination role
  • Experience in a team-based service environment
  • Interpersonal communication skills with exceptional listening abilities
  • Compassionate, kind, and open-minded
  • Excellent written and verbal communication skills
  • Some clinical experience is a plus, such as EMT, MA, CNA, or Phlebotomy certification


  • You will benefit from Evergreen Nephrology’s exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at four weeks for full-time employees, 12 paid holidays per year, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance.
  • We are proud to offer family-friendly policies that support paid parental leave and flexible work arrangements.
  • We commit to a robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology.
  • As an inclusive and diverse team, 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.