• Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations. • Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey. • Serving as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system and maintaining compliance with the primary care team’s/nephrologist’s treatment plan. • Performing assessments and identifying the needs, including social determinants of health, of panel patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans through comprehensive evaluations. • Coordinating the interdisciplinary approach to achieving continuity of care and reducing fragmentation, focusing on kidney disease progression management, utilization management, and provider coordination through active care plan management. • Monitoring and evaluating the effectiveness of care management plans regularly, modifying interventions as necessary. • Following evidence-based care management guidelines and established workflow protocols to deliver high quality, efficient, patient-centered care that aligns with Evergreen’s goals, quality metrics, and regulatory and payer requirements. • Collaborating with physician partners, community providers, APPs, and other clinical disciplines to create, implement, and manage integrated care plans. • Identifying cost-effective measures for patients that support value-based care goals of improving patient outcomes and quality while effectively managing resource utilization. • Facilitating patient and caregiver education on treatment options and empowering patients to make informed decisions about their care. • Supporting seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with IDTs. • Actively participating in clinical huddles, and patient care conferences for patients under your care management as needed. • Engaging in continuous, organizational process improvement to identify opportunities for improvement and execute action plans to optimize care management workflows, patient engagement processes, customer/patient care efforts, and other protocols. • Preparing reports and other deliverables to communicate program changes or developments to appropriate stakeholders. • Collecting data to prepare and deliver reports alongside program leaders on program success, patient outcomes, and patient/caregiver satisfaction. • Other duties consistent with this role, as assigned.