Job Overview

• Job type: Full time/ Part time
• Work setting: Work from home
• Location: Remote (Worldwide)
• Salary: $55,000-$65,000 annually
• Employer: Evergreen Nephrology

Responsibilities

Some responsibilities may vary based on specific patient programs, but this role’s primary duties include the following:

• Patient Engagement & Outreach
  • Perform monthly CCM touchpoints for assigned patient panels.
  • Build strong, ongoing relationships with patients and caregivers through regular outreach.
  • Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls.
  • Explain CCM participation and reinforce program benefits.
• Clinical Assessments & Judgment
  • Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.).
  • Evaluate changes in condition using licensed clinical judgment.
  • Assess medication adherence issues, side effects, or confusion about regimen.
  • Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals).
• Escalation, Coordination & Provider Communication
  • Escalate urgent issues based on defined triage pathways (same-business-day or immediate).
• Collaborate with the provider team on symptom changes, new concerns, or medication-related issues.
  • Route EHR messages with clinically relevant documentation.
  • Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care.
• Care Plan Reinforcement & Patient Education
  • Reinforce provider-developed CKD and chronic disease care plans.
  • Provide clinical explanation of symptom management instructions (within LPN scope).
  • Support adherence to medications, lifestyle changes, and follow-up instructions.
  • Identify social, behavioral, or access barriers and determine appropriate interventions or referrals.
• Documentation, EHR Updates & Compliance
  • Document all patient interactions clearly in both the EHR and CCM patient management platform.
  • Track and log qualifying CCM time accurately for billing compliance.
  • Ensure documentation meets regulatory, internal QA, and partner expectations.
  • Maintain high call quality and adherence to scripting and workflow pathways.
• Quality, Performance & Continuous Improvement
  • Maintain or exceed:
    • ≥80% monthly engagement
    • ≥90% billable conversion
    • High QA/documentation accuracy scores
  • Participate in peer reviews, QA audits, coaching sessions, and continuous education.
  • Identify recurring patient needs and communicate trends to the Program Manager.
• Other duties consistent with this role, as assigned.

Requirements

• Active LPN or Licensed Vocational Nurse (LVN) license
• Bilingual (Spanish/English)
• Minimum 1–2 years of clinical experience in:
  • Ambulatory care
  • Population health
  • Care coordination
  • Case management
• Strong clinical assessment, communication, and documentation skills.
• Comfortable working in two systems (EHR + CCM platform) simultaneously.
• Ability to manage a structured, metric-driven workflow with reliability.
• 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

Preferred Qualifications

• Experience in chronic disease management
• Prior work in virtual care, remote nursing, or telehealth programs.
• Familiarity with CCM regulatory requirements.
• Strong patient education and motivational interviewing skills.

Compensation

The pay range for this role is $55,000-$65,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

This role is also eligible for a quarterly bonus.

Benefits

Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:

• Paid time off starting at 4 weeks for full-time employees
• 12 paid holidays per year
• Medical, dental, vision and life insurance, including an HSA with employer match
• Reimbursement for continuing medical education for eligible roles
• A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure
• Paid parental leave
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.

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