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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   As a Nurse Care Manager supporting the Evergreen Aligned (EGA) team with Evergreen Nephrology, you are responsible for supporting care delivery within the EGA model by partnering with Advanced Practice Providers (APPs) to ensure effective execution of individualized care plans for patients with chronic kidney disease, hypertension, diabetes, and congestive heart failure.   This role focuses on enhancing clinical outcomes, patient engagement, and care coordination through education, remote monitoring, medication management, and longitudinal patient support in a virtual care environment.   Role Responsibilities   Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:   Visit Preparation & Coordination   Conducts pre-visit planning by reviewing patient records, identifying care gaps, and ensuring necessary clinical information, laboratory results, and assessments are available for scheduled visits.   Care Plan Execution & Clinical Support   Reinforces APP-directed care plans through post-visit follow-up and ensures patient understanding and adherence.   Monitors completion of key care elements including labs, medications, and referrals.   Chronic Kidney Disease Management & Education   Provides stage-based CKD education, reinforcing guideline-directed therapies, and key lifestyle strategies.    Supports early patient understanding of disease progression and renal replacement options.   Hypertension Management & Education   Educates accurate home BP monitoring and trends data to identify uncontrolled hypertension or hypotension.    Reinforces protocol-driven treatment adjustments and lifestyle interventions.   Diabetes Management & Education   Reviews SMBG/CGM data to identify glycemic trends and support timely escalation of care.    Educates on hypo-/hyperglycemia management and reinforces medication adherence and A1c monitoring.   Congestive Heart Failure Management & Education   Monitors weight, blood pressure, symptoms, and other clinical indicators to identify early signs of heart failure exacerbation.    Reinforce guideline-directed medical therapy, sodi