New Nurse Care Manager - Compassionate Care Program (CST or PST - Bilingual)

In this role you will manage the healthcare journey of patients referred to the program based on their unique healthcare needs, goals, and wishes. You will collaborate with a team of Physicians, Advanced Practice Providers, and interdisciplinary team members to manage patients referred to the ECCP by taking full ownership of patients within your panel, focusing on helping patients with kidney disease understand their diagnosis and prognosis as well as services available to them so they are empowered to make healthcare decisions they are comfortable with. You will perform assessments and advance care planning conversations to identify their needs based on their values, goals, and preferences. You will assess patients for hospice appropriateness and hospice-mindedness. From this assessment, you will either refer patients to the appropriate program within Evergreen for ongoing kidney care management with or without dialysis, and or will coordinate continued care under their nephrologist; or coordinate a transition to hospice care in collaboration with community providers. You will act as a clinical liaison and educator, working closely with the Senior Director of the ECCP, to provide resources and training both internally and externally regarding identifying patients who need advance care planning and goals or care discussions, and/or patients who may be appropriate for hospice care.