Program Manager - Chronic and Complex Care Management & Transitions of Care

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.

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: As the Program Manager of Chronic and Complex Patient Management (CCPM) and Transitions of Care (TOC) with Evergreen Nephrology, you will lead a team focused on delivering longitudinal, patient-centered care for individuals with complex and chronic conditions, including kidney disease, diabetes, heart failure, and other comorbidities. In this role, you will provide collaborative, supportive leadership and oversee the day-to-day operations of the care management team, ensuring consistent execution of proactive care strategies that improve patient outcomes. You will leverage your clinical and operational expertise to guide the management of high-risk populations, ensure adherence to established care pathways, and reduce complications, avoidable hospital admissions, and overall healthcare utilization. You will be accountable for CCPM and TOC program performance, driving results against key performance indicators (KPIs) and quality metrics. Additionally, you will support ongoing team development through coaching, training, and performance management to ensure delivery of high-quality, efficient, and patient-centered care aligned with Evergreen’s standards.

Oversee day-to-day operations for the CCPM and TOC care management teams, ensuring efficient workflows, standardized processes, and consistent achievement of program goals. Ensure delivery of high-quality longitudinal chronic/complex care management and best-in-class transitions of care, including adherence to clinical pathways, protocols, and documentation standards. Continuously evaluate and improve the performance of CCPM and TOC programs and team members, consistent with Evergreen’s performance management philosophy. Develop and implement collaborative strategies to improve program performance and patient outcomes (e.g., chronic disease control, complication prevention, and reduced readmissions) while ensuring patient and provider partner satisfaction. Support newly hired CCPM/TOC team members through orientation and onboarding; provide ongoing training, coaching, and development for established team members. Perform regular call and documentation (chart) audits to support performance management and identify opportunities for continuous improvement. Prepare performance reports, dashboards (as applicable), and meeting materials for CCPM and TOC programs for internal and external audiences. Oversee TOC workflows that support timely post-discharge outreach, medication reconciliation support, follow-up appointment coordination, and issue escalation to reduce avoidable readmissions. Develop and foster relationships with key stakeholders (e.g., IDT members, market leaders, and other program leaders) to drive outcomes through collaboration and cross-program partnership across CCPM and TOC. Build and maintain effective communication strategies between Evergreen and market stakeholders to foster strong relationships that support improved patient outcomes, in collaboration with market leaders. Be a Culture Champion by cultivating a culture of high performance, transparency, trust, and collaboration. Other duties consistent with this role, as assigned.