Care Coordinator, LPN (Bilingual)

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