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care coordinator

Chase Brexton Health Care

<div>
 JOB SUMMARY: The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to CBHC staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources). This is a hybrid position, and the staff member is expected to be licensed and based in Maryland.
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  Major Duties And Responsibilities
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 Analytical and Critical Thinking
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 Work to develop systems and processes to engage patients in self-management and care navigation.
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   Ensure that appropriate community resources, home care and ancillary services are in place and being delivered.
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   Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients
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   Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population.
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   Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients.
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   Access appropriate resources inside and outside the organization to meet the needs of the patient.
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   Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Teamwork
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   Role model and mentor others, including RN Care Managers, to assess and address the physical, functional, social, psychological, environmental, learning and financial needs of patients.
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  </li>
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 Communication
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   Deliver, and assist others to also provide, appropriate interventions which demonstrate knowledge of, and sensitivity toward, cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
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   Facilitate disease prevention and health promotion with nursing staff, patients and families. Patient Focus
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   Provide education, information, and support related to care goals of patients.
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   Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Checking, Examining, and Recording
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   Maintain accurate patient records and patient confidentiality. Willingness to Learn
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   Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.
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   Attend training sessions and staff meetings as assigned.
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  </li>
 </ul>
 SKILLS AND ABILITIES:
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 Able to prioritize competing responsibilities and manage complex caseloads.
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   Motivational interviewing skills.
  </li>
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   Supportive coaching and mentorship to colleagues at clinic sites, including RN Care Managers, around care coordination and addressing social determinants of health.
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   Experience with documentation in an Electronic Medical Record
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   Ability to work with computers in word processing, and database applications preferred.
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   CPR certified by scheduled start date.
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   Must be flexible and adapt to a changing environment.
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 </ul>
 EDUCATION AND/OR EXPERIENCE:
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 Graduate from an Accredited School of Nursing; Current Maryland Nursing License
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   At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting.
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   Chronic disease management experience
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   Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc.
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 </ul>
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  <br/>
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 Preferred: Case Management Certification
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 WORKING CONDITIONS/PHYSICAL DEMANDS:
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   Work is typically performed in an office environment. Depending on client/population needs, may also include clinical and community and/or home-based activities, as appropriate to program. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
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  </li>
 </ul>
 My signature below indicates that I have reviewed this job description. I understand the specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
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 ___________________________________________________ _________________
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 Employee Signature
</div>


Population Health RN Care Coordinator

Evergreen Nephrology

<div><p><b>Who We Are</b></p>
<p>
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.</p>
<p>
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.</p>
<p><b>
Who You Are</b></p>
<p>
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.</p>
<p><b>
Your Role</b></p>
<p>
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.</p>
<p>
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.</p>
<p>
The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.</p>
<p>
While this position is <b>fully remote</b>, you must be able to work 8:00am &ndash; 5:00pm in the Pacific time zone.</p>
<p><b>
Role Responsibilities</b></p>
<p>
Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:</p>
<ul>
<li>Patient Enrollment &amp; Eligibility
<ul><li>Support CCM patient enrollment and onboarding activities.</li>
<li>Verify eligibility based on Evergreen and payer program guidelines.</li>
<li>Ensure patient consent documentation is completed prior to outreach.</li>
<li>Proactively maintain patient engagement regularly.</li>
<li>Identify inactive or non-engaged patients and escalate appropriately.</li>
</ul></li><li>Patient Outreach &amp; Engagement
<ul><li>Conduct text &amp; telephonic outreach to enrolled CCM patients weekly.</li>
<li>Achieve required engagement time standards aligned with Medicare CCM billing requirements.</li>
<li>Support achievement of required engagement time for billing compliance.</li>
<li>Reinforce provider-directed care plans during patient interactions.</li>
<li>Identify barriers to adherence including medication access, transportation, or social needs.</li>
</ul></li><li>Expected activities include:
<ul><li>High-volume outbound patient calling and texting.</li>
<li>Follow-up outreach attempts.</li>
</ul></li><li>Documentation &amp; Billing Compliance
<ul><li>Document patient interactions accurately within the CCM patient management platform and EHR systems.</li>
<li>Track engagement time consistent with Medicare CCM billing requirements.</li>
<li>Maintain audit-ready documentation standards.</li>
<li>Ensure HIPAA and PHI compliance.</li>
</ul></li><li>Patient Care Coordination &amp; Clinical Workflow
<ul><li>Facilitate patient access to their referring provider and clinical staff.</li>
<li>Support care transitions following hospitalizations or ED visits.</li>
<li>Coordinate referrals and follow-up appointments.</li>
<li>Escalate symptom concerns or medication issues to licensed clinical staff.</li>
</ul></li><li>Preferred experience includes:
<ul><li>Chronic kidney disease patient populations.</li>
<li>Dialysis patient coordination.</li>
<li>Medication adherence monitoring.</li>
<li>Kidney transplant or specialty referrals.</li>
</ul></li><li>Technology &amp; Communication
<ul><li>Utilize CCM platform and EHR systems daily.</li>
<li>Manage patient messaging workflows.</li>
<li>Collaborate with remote clinical and operational teams.</li>
</ul>
</li></ul><p><b>Required Qualifications</b></p>
<ul>
<li>Certified Medical Assistant</li>
<li>1&ndash;3 years healthcare experience</li>
<li>Chronic disease or nephrology experience is preferred.</li>
<li>Strong clinical assessment, communication, and documentation skills.</li>
<li>Comfortable working in two systems (EHR + CCM platform) simultaneously.</li>
<li>Ability to manage a structured, metric-driven workflow with reliability.</li>
<li>Intermediate skills with MS Office Suite of products including Outlook and Teams</li>
<li>Able to work effectively in a primarily remote environment:
<ul><li>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</li>
<li>Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role</li>
<li>Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information</li>
</ul>
</li></ul><p><b>Preferred Qualifications</b></p>
<ul>
<li>Experience in chronic disease management</li>
<li>Prior work in virtual care, remote nursing, or telehealth programs.</li>
<li>Familiarity with CCM regulatory requirements.</li>
<li>Strong patient education and motivational interviewing skills.</li>
</ul>
<p><b>Compensation</b></p>
<p>
The pay range for this role is <b>$45,000 to $52,000 </b>annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.</p>
<p>
This role is also eligible for a bonus.</p>
<p><b>
Benefits
</b></p><p>Evergreen Nephrology's total rewards program is designed to support you in and outside of work. You can expect:</p>
<ul>
<li>Paid time off starting at 4 weeks for full-time employees</li>
<li>12 paid holidays per year</li>
<li>Medical, dental, vision and life insurance, including an HSA with employer match</li>
<li>Reimbursement for continuing medical education for eligible roles</li>
<li>A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure</li>
<li>Paid parental leave</li>
<li>A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology</li></ul><br>
<p></p>
<p>
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.</p><br>
<p></p>
<p>
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.</p></div>

Remote Medical Assistant - Pacific Time

Johns Hopkins University

<p></p><div><p>The Department of Psychiatry Behavioral Medicine is seeking a<b><i> Medical Office Coordinator </i></b>to coordinate activities and provide secretarial support for a multi-faceted clinical/research office to ensure a smoothly functioning office and good patient relations. Interact with patients, patients&rsquo; family members, referring physicians, and third party carriers with regard to patient-related issues. Work with others in a team environment.</p><p></p><p><b><br>
Specific Duties and Responsibilities</b></p><ul><li>
Coordinates a multi-faceted clinical/research office.
</li><li>Assists patients, referring physicians, and third-party carriers to resolve patient related issues. Researches and prepares specialized reports and budgets.</li><li>
Schedules patients for laboratory tests, medical examinations, and consultations.
</li><li>Acquires medical/psychiatric records of patients.
</li><li>Relay information to patients regarding preparation for laboratory tests and examinations. Maintains familiarity with various types of medical insurance to explain these plans.
</li><li>Obtains pre-certifications as required by patients' health care insurers or managed care providers. Assists patients or family members with completion of medical insurance forms.
</li><li>Informs patients of costs of care being provided, and guides them to appropriate resources for further information, guidance, or assistance.
</li><li>Arranges or assists in arranging patient transportation.
</li><li>Types routine correspondence and reports from dictation or handwritten copy using personal computer.
</li><li>Transcribes machine dictated medical reports and other documentation using medical terminology.
</li><li>Performs data entry of consult questionnaires.
</li><li>Uses personal computer to prepare manuscripts, grant proposals, statistical reports, tables, and charts using knowledge of scientific, medical, literary, or other technical terms.
</li><li>Answer telephone, screens callers, relays messages, and greets visitors.
</li><li>Maintains calendar, schedules appointments and meeting rooms.
</li><li>Opens, sorts and screens mail. Files in alphanumeric order and locates material from files. Assists with making routine travel and accommodation arrangements.
</li><li>Coordinates the servicing of office equipment.
</li><li>Operates personal computer to access e-mail, electronic calendars, and other basic office support software. Uses automated systems to access, enter, and edit patient information.
</li><li>Completes various request forms for office supplies and equipment as directed.</li><li>
Performs miscellaneous related duties as assigned.</li><li>
Must adhere to Service Excellence Standards: customer relations, self-management, teamwork, communications, ownership/accountability, continuous performance improvement.</li></ul><p></p><p><b><br>
Special knowledge, skills, and abilities</b></p><ul><li>
Ability to work independently.</li><li>
Attention to detail and good proofreading skills.</li><li>
Excellent communication skills both written and oral.</li><li>
Excellent organizational skills require balancing multiple assignments.</li><li>
Ability to interact effectively with individuals at all levels and from diverse cultures.</li><li>
Clinical sensitivity required.</li><li>
Knowledge of medical terminology.</li><li>
Experience in the Johns Hopkins system strongly preferred.</li></ul><br>
<b>
Minimum Qualifications</b><br>
<ul><li>
High School Diploma or graduation equivalent.</li><li>
Two years administrative experience.</li><li>
Additional education may substitute for required experience, and additional related experience may substitute for required education beyond a high school diploma/graduation equivalent, to the extent permitted by the JHU equivalency formula.</li></ul><p></p><p><br>
Classified Title: Medical Office Coordinator
<br>
Role/Level/Range: ATO 40/E/02/OD
<br>
Starting Salary Range: $16.20 - $28.80 HRLY ($46,800 targeted; Commensurate w/exp.)<br>
Employee group: Full Time<br>
Schedule: Monday - Friday, 8:30am - 5:00pm<br>
FLSA Status: Non-Exempt<br>
Location: School of Medicine Campus<br>
Department name: 10003139-SOM Psy Behavioral Medicine<br>
Personnel area: School of Medicine</p></div><p></p>

Medical Office Coordinator (Psychiatry Behavioral Medicine)

<div><p>Plastic Surgery &amp; Reconstructive Surgery are seeking a<b><i> Sr. Medical Office Coordinator </i></b>to coordinate the day-to-day activities of a multi-faceted surgical practice to ensure a smoothly functioning office and good patient relations. Adapt to changes in technology and software to ensure efficient office practice. Support surgeons in efficient use of operating room and clinic time. Provide administrative support for medical matters on behalf of physicians, as well as general academic/general administrative support.</p><p></p><p><b><br>
Specific Duties &amp; Responsibilities</b></p><p></p><ul><li>
Coordinate with patient and hospital, complex procedure scheduling including dates for surgery and office visits, preparation and dissemination of pre-operative and hospital admission information.
</li><li>Collect insurance information and complete surgery scheduling and registration in EPIC.
</li><li>Support the physician with insurance preauthorization and single case agreement processes by submitting necessary clinical information as instructed by the physician.</li><li>
Coordinate follow-up office visits by providing information about treatment and testing locations.
</li><li>Schedule lab test and other procedures and/or coordinate with other areas to complete scheduling process.
</li><li>When clinic is cancelled, coordinate with Access Services and Patient Service Coordinators to reschedule physician and/or testing appointments.
</li><li>Coordinate with patient and/or referring physician to obtain outside medical records. Refer patient to appropriate resources.
</li><li>Review clinic schedules and adjust as appropriate.</li><li>
Act as a liaison for patients, coordinating future consultations, diagnostics tests, or procedures.</li><li>
Professionally and efficiently manage incoming calls and requests from patients, surgeons and fellow staff members to ensure that issues are resolved both promptly and thoroughly.
</li><li>Provide quality service and support to patients in a variety of areas which may include, but not limited to scheduling, registration and care coordination.
</li><li>May require travel to multiple work sites.
</li><li>Perform other duties as required.</li></ul><p></p><p><b><br>
Special Knowledge, Skills, and Abilities</b></p><ul><li>
Intermediate computer and proofreading skills.
</li><li>Able to work independently.</li><li>
Support fellow staff members and promote team success.</li></ul><p><br>
</p><br>
<br>
<b>Minimum Qualifications</b><br>
<ul><li>
High School Diploma or graduation equivalent</li><li>
Three years progressively responsible medical office experience.
</li><li>Medical Terminology</li><li>
Additional education may substitute for required experience, and additional related experience may substitute for required education beyond a high school diploma/graduation equivalent, to the extent permitted by the JHU equivalency formula.</li></ul><br>
<b>
Preferred Qualifications</b><br>
<ul><li>
Two years&rsquo; college or equivalent work experience.</li><li>
Knowledge of patient registration and scheduling in Epic and experience in the Johns Hopkins system strongly preferred.</li></ul><p></p><p><br>
Classified Title: Sr. Medical Office Coordinator<br>
Role/Level/Range: ATO 40/E/02/OE
<br>
Starting Salary Range: $18.20 - $33.90 HRLY (Commensurate w/exp.)<br>
Employee group: Full Time<br>
Schedule: Mon-Fri/40 hrs<br>
FLSA Status: Non-Exempt<br>
Location: Hybrid/School of Medicine Campus<br>
Department name: SOM Plastic Surgery<br>
Personnel area: School of Medicine</p></div><p></p>

Sr. Medical Office Coordinator (Plastic & Reconstructive Surgery)

Porter Cares, Inc.

<div><div><b>Care Guide Medical Assistant</b></div>
<div></div>
<div><b>Full Time</b></div>
<div><b>Hybrid</b></div>
<div><b>Must reside in Baltimore, MD</b></div>
<div></div>
<div><b>About Porter</b></div>
<div>Porter is a fast-growing healthcare-technology and services company, built on the mission of simplifying and improving the care-at-home journey for patients and members. Leveraging advanced analytics, AI-driven tools, and a dedicated care-guide team, Porter delivers personalized care coordination, risk-adjustment support, and comprehensive member services &mdash; helping payers, providers, and members navigate complex care requirements with clarity and compassion. Porter stands at the forefront of care-coordination innovation, striving to deliver high-quality, efficient, and patient-centric support across the care continuum.</div>
<div></div>
<div><b>About the Role</b></div>
<div>The <b>Care Guide</b> acts as a personal resource to Porter members (customers, patients, caregivers) to assist with a wide variety of healthcare-related needs and helps them to be successful in navigating through their healthcare journey. Ideal candidates will have the experience, drive, and compassion to seek out opportunities to proactively identify needs and resources to meet those needs, help members to understand the complexities of our healthcare system, ensure that members are fully utilizing their insurance plan benefits, and reduce costs (e.g., locate cost-effective solutions, identify the most appropriate site of care, help prevent avoidable admissions/readmissions, etc.).</div>
<div>Job responsibilities include, but are not limited to:</div>
<ul><li> Scheduling practitioner visits for in-home or health assessment</li></ul>
<ul><li> Assist members with all aspects of the Porter relationship, account, products, and Porter's Member Platform</li></ul>
<ul><li> Proactively identify the needs of members and provide personalized service</li></ul>
<ul><li> Act as a comprehensive resource for assisting members with a broad range of healthcare questions and needs</li></ul>
<ul><li> Identify and document Social Determinants of Health (SDOH) and assist with identification of community resources</li></ul>
<ul><li> Facilitate communications to bridge between patients and appropriate clinical teams as needed</li></ul>
<ul><li> Help identify and facilitate education resources to assist members in their self-care</li></ul>
<ul><li> Interpret and articulate Health Plan benefits and coverage, and ensure that members are fully utilizing their benefits</li></ul>
<ul><li> Be readily available to assist members via omnichannel resources (phone, email, chat)</li></ul>
<ul><li> Manage &amp; update customer CRM (Salesforce Service Cloud)</li></ul>
<ul><li> Document relevant details about all patient/Caregiver interactions.</li></ul>
<ul><li> Boost member satisfaction and loyalty by providing consistently excellent experience and striving to go above and beyond.</li></ul>
<ul><li> Assist members with hospital discharges (when applicable):</li></ul>
<div>o Coordinates and facilitates patient discharge planning in collaboration with other healthcare professionals.</div>
<div>o Collaborate with patients, caregiver(s), and healthcare team to facilitate a discharge process that enhances patient satisfaction and adherence to discharge orders, and ensures efficiency of time and resources involved in each patient discharge.</div>
<div>o Review case notes from Hospital providers to identify Durable Medical Equipment (DME) needs, schedule requested appointments, and/or facilitate other needs required to ensure optimal outcomes for patients post-discharge.</div>
<div>o Act as concierge to identify and facilitate DME procurement and follow-up appointment needs for patients</div>
<div></div>
<div><b>Schedule: Remote 4 days a week, on-site every Friday</b></div>
<div><b>Work Health fairs once a month</b></div>
<div></div>
<div><b>What You'll Need</b></div>
<div></div>
<div><b>Qualifications That Are Preferred</b></div>
<ul><li> 2-3 years of experience working in direct contact with patients in a healthcare setting</li></ul>
<ul><li> Demonstrated ability to interpret and apply health insurance benefits</li></ul>
<ul><li> A strong sense of empathy, compassion, and friendliness (extroverted and people-oriented)</li></ul>
<ul><li> Drive to go above and beyond to ensure that members/patients/caregivers feel genuinely supported and valued during challenging times</li></ul>
<ul><li> Exceptional communication skills, both written and oral, with the ability to assist others (customers and coworkers alike) with sincerity, respect, and compassion</li></ul>
<ul><li> Strong time management and organizational skills to juggle meetings and various administrative requirements while keeping member needs at the forefront</li></ul>
<ul><li> Must be an excellent listener, both to ensure that the member feels valued/respected and to identify any potential needs that the member may not be directly articulating</li></ul>
<ul><li> Ability to work with team to cover on-call and holiday schedules as needed</li></ul><br>
<div></div>
<div></div>
<div><b>Qualifications That Are Required</b></div>
<ul><li> High School Diploma</li></ul>
<ul><li> Current Medical Assistant Certification</li></ul>
<ul><li> Ability to keep all company-sensitive documents and systems secure</li></ul>
<div></div>
<div><b>The Benefits of Working with Porter</b></div>
<div>Benefits &ndash; Medical Dental Vision</div>
<div>Paid Holidays</div>
<div>Paid Time Off</div>
<div>Equipment Support</div>
<div>A fun team and special culture</div>
<p>
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.</p></div>

Care Guide Medical Assistant

<div><p><b>Who We Are</b></p>
<p>
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.</p>
<p>
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.</p>
<p><b>
Who You Are</b></p>
<p>
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.</p>
<p><b>
Your Role</b></p>
<p>
As a Licensed Practical Nurse (LPN) with Evergreen Nephrology, you are responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns, reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy across both the EHR and partner technology platform. This position requires clinical judgment, licensed expertise, and the ability to support patients between office visits while collaborating closely with Evergreen's providers, care teams, and leadership. LPNs are essential to delivering a safe, compliant, clinically credible Connected Care Program.</p>
<p>
The program uses SMS as the first-line channel for patient engagement, with phone outreach used when appropriate.</p>
<p>
While this position is <b>fully remote</b>, you must be able to work from 8:30am &ndash; 5pm in the Eastern time zone.</p>
<p><b>
Role Responsibilities</b></p>
<p>
Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:</p>
<ul>
<li>Patient Engagement &amp; Outreach
<ul><li>Perform monthly CCM touchpoints for assigned patient panels.</li>
<li>Build strong, ongoing relationships with patients and caregivers through regular outreach.</li>
<li>Review patient chart data (diagnoses, kidney disease history, medications, labs, imaging, treatment cycles) before calls.</li>
<li>Explain CCM participation and reinforce program benefits.</li>
</ul></li><li>Clinical Assessments &amp; Judgment
<ul><li>Conduct structured symptom assessments (pain, fatigue, neuropathy, SOB, nausea, etc.).</li>
<li>Evaluate changes in condition using licensed clinical judgment.</li>
<li>Assess medication adherence issues, side effects, or confusion about regimen.</li>
<li>Identify clinical red flags requiring escalation (e.g., worsening symptoms, new SOB, uncontrolled pain, concerning vitals).</li>
</ul></li><li>Escalation, Coordination &amp; Provider Communication
<ul><li>Escalate urgent issues based on defined triage pathways (same-business-day or immediate).</li>
</ul></li><li>Collaborate with the provider team on symptom changes, new concerns, or medication-related issues.
<ul><li>Route EHR messages with clinically relevant documentation.</li>
<li>Assist in coordinating care: scheduling follow-up, arranging labs, ensuring nephrology appointments are kept, and reducing missed care.</li>
</ul></li><li>Care Plan Reinforcement &amp; Patient Education
<ul><li>Reinforce provider-developed CKD and chronic disease care plans.</li>
<li>Provide clinical explanation of symptom management instructions (within LPN scope).</li>
<li>Support adherence to medications, lifestyle changes, and follow-up instructions.</li>
<li>Identify social, behavioral, or access barriers and determine appropriate interventions or referrals.</li>
</ul></li><li>Documentation, EHR Updates &amp; Compliance
<ul><li>Document all patient interactions clearly in both the EHR and CCM patient management platform.</li>
<li>Track and log qualifying CCM time accurately for billing compliance.</li>
<li>Ensure documentation meets regulatory, internal QA, and partner expectations.</li>
<li>Maintain high call quality and adherence to scripting and workflow pathways.</li>
</ul></li><li>Quality, Performance &amp; Continuous Improvement
<ul><li>Maintain or exceed:
<ul><li><ul><li>80% monthly engagement</li></ul></li>
<li><ul><li>90% billable conversion</li></ul></li>
<li>High QA/documentation accuracy scores</li>
</ul></li><li>Participate in peer reviews, QA audits, coaching sessions, and continuous education.</li>
<li>Identify recurring patient needs and communicate trends to the Program Manager.</li>
</ul></li><li>Other duties consistent with this role, as assigned.</li>
</ul>
<p><b>Required Qualifications</b></p>
<ul>
<li>Active LPN or Licensed Vocational Nurse (LVN) license</li>
<li>Minimum 1&ndash;2 years of clinical experience in:
<ul><li>Ambulatory care</li>
<li>Population health</li>
<li>Care coordination</li>
<li>Case management</li>
</ul></li><li>Strong clinical assessment, communication, and documentation skills.</li>
<li>Comfortable working in two systems (EHR + CCM platform) simultaneously.</li>
<li>Ability to manage a structured, metric-driven workflow with reliability.</li>
<li>Intermediate skills with MS Office Suite of products including Outlook and Teams</li>
<li>Able to work effectively in a primarily remote environment:
<ul><li>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</li>
<li>Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role</li>
<li>Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information</li>
</ul>
</li></ul><p><b>Preferred Qualifications</b></p>
<ul>
<li>Experience in chronic disease management</li>
<li>Prior work in virtual care, remote nursing, or telehealth programs.</li>
<li>Familiarity with CCM regulatory requirements.</li>
<li>Strong patient education and motivational interviewing skills.</li>
</ul>
<p><b>Compensation</b></p>
<p>
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.</p>
<p>
This role is also eligible for a quarterly bonus.</p>
<p><b>
Benefits
</b></p><p>Evergreen Nephrology's total rewards program is designed to support you in and outside of work. You can expect:</p>
<ul>
<li>Paid time off starting at 4 weeks for full-time employees</li>
<li>12 paid holidays per year</li>
<li>Medical, dental, vision and life insurance, including an HSA with employer match</li>
<li>Reimbursement for continuing medical education for eligible roles</li>
<li>A 401(k) program where Evergreen matches up to 4% of contributions after six months of tenure</li>
<li>Paid parental leave</li>
<li>A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology</li></ul><br>
<p></p>
<p>
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.</p><br>
<p></p>
<p>
If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at recruiting@evergreennephrology.com.</p></div>

Remote Licensed Practical Nurse - Eastern Time

Baltimore Crisis Response, Inc

Description
<br><div><p><b>Case Manager
</b> Baltimore, Maryland
 $20.00-$23.00 Hourly
 Full-Time | Shifts: 8:00M-4:00PM | Monday- Friday
</p><p>Being the Leader Communities Need in Moments of Crisis.
</p><p></p><p><b>About Us
</b></p><p>Baltimore Crisis Response, Inc. (BCRI) is a nationally recognized nonprofit and Baltimore&rsquo;s only comprehensive crisis response system. Since 1992, we&rsquo;ve been at the forefront of behavioral health crisis care &mdash; providing timely, community-based services for individuals and families experiencing mental health and substance use challenges.
</p><p></p><p><b>The Opportunity
</b></p><p>We are seeking a Case Manager to support individuals as they move through different levels of care. In this role, you&rsquo;ll partner with clients and their care teams to coordinate services, develop discharge plans, and connect individuals with the community resources they need for ongoing recovery. You&rsquo;ll also play a hands-on role in monitoring daily progress, supporting treatment goals, and fostering smooth transitions across the system of care.
</p><p>This is more than case coordination &mdash; it&rsquo;s an opportunity to advocate for individuals, strengthen continuity of care, and make a meaningful impact on recovery outcomes in Baltimore.<br>
</p><p></p><p><b>What You&rsquo;ll Do
</b></p><ul><li>Supports the delivery of care and engagement of individuals under care by participating in group supervision and by reviewing evaluations, assessments, treatment plans, and progress notes to understand the unique needs, strengths, preferences, and goals.
</li><li>Assesses the needs of the individual receiving care across multiple domains including mental health, medical, social, and other services by completing needs assessment and other appropriate tools.
</li><li>Partners with the client receiving care and their care team to identify clinical goals, interventions, and strategies, documenting in the discharge plan.
</li><li>Initiates and submits referrals to medical and Behavorial health care, community programs, and service providers.
</li><li>Develops and maintains strong working knowledge of care partners, service providers, and stakeholders across the system of care, maintaining a positive rapport.
</li><li>As approved and assigned, uses company vehicles to provide transportation for individuals entering, receiving, or discharged from care.
</li><li>Collaborates with care team members for admission and discharge from the residential milieu, engaging external stakeholders when appropriate and as directed during these transitions.
</li><li>Serves as a liaison as assigned and appropriate for internal and external stakeholders, care partners, and visitors.
</li><li>Demonstrates adherence to company policies, expectations, and behavioral competencies, both explicit and implicit.
</li><li>All tasks, projects, and/or duties as assigned and authorized, as determined by Direct Supervisor (or designated delegate) to be congruent with the role.</li></ul></div>
<br>Qualifications
<br><div><p><b>Qualifications
</b></p><ul><li>High school diploma or equivalent.
</li><li>Bachelor&rsquo;s Degree preferred
</li></ul><p><b>Additional
</b></p><ul><li>Applicant must have a valid MD driver&rsquo;s license and will transport clients using a company vehicle when needed.
</li></ul><p></p><p><b>Why Join BCRI
</b> Medical, Dental, and Vision Insurance.
 403(b) Retirement Plan
 Generous PTO &ndash; Vacation, Sick, Personal, and Holidays.
 Tuition Reimbursement &amp; Professional Development Support.
 Be part of an innovative, impact-driven team shaping the future of crisis care.
</p><p></p><p><b>Make a Difference. Lead with Compassion.
</b><br>
This is more than a leadership role &mdash; it&rsquo;s a chance to help individuals and families find stability in their most vulnerable moments.
</p><p> Apply today and become a guiding force for change.</p></div><p></p>

Case Manager (10237)

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