Care Coordinator

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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. 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. Your Role The Evergreen Chronic Care Management (CCM) Medical Assistant (Care Coordinator) supports proactive care coordination services for patients with complex chronic conditions, including chronic kidney disease (CKD), hypertension, diabetes, cardiovascular disease, and related comorbidities. Working under Evergreen’s clinical supervision, the Care Coordinator conducts patient outreach, creates, maintains, and reinforces established care plans, supports documentation compliance, and coordinates communication between patients, providers, and healthcare partners. This role is outreach-driven and operationally focused, requiring strong organization, patient communication skills, and the ability to manage a high-volume patient panel. Experience supporting nephrology or CKD patient populations is strongly preferred. The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate. While this position is fully remote , you must be able to work 8:00am – 5:00pm in the central time zone. Role Responsibilities Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following: Patient Enrollment Eligibility Support CCM patient enrollment and onboarding activities. Verify eligibility based on Evergreen and payer program guidelines. Ensure patient consent documentation is completed prior to outreach. Proactively maintain patient engagement regularly. Identify inactive or non-engaged patients and escalate appropriately. Patient Outreach Engagement Conduct text telephonic outreach to enrolled CCM patients weekly. Achieve required engagement time standards aligned with Medicare CCM billing requirements. Support achievement of required engagement time for billing compliance. Reinforce provider-directed care plans during patient interactions. Identify barriers to adherence including medication access, transportation, or social needs. Expected activities include: High-volume outbound patient calling and texting. Follow-up outreach attempts. Documentation Billing Compliance Document patient interactions accurately within the CCM patient management platform and EHR systems. Track engagement time consistent with Medicare CCM billing requirements. Maintain audit-ready documentation standards. Ensure HIPAA and PHI compliance. Patient Care Coordination Clinical Workflow Facilitate patient access to their referring provider and clinical staff. Support care transitions following hospitalizations or ED visits. Coordin

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