Nurse Navigator (RN)

Evergreen Nephrology • Peoria, AZ

5d • Hybrid

About The Position

Evergreen Nephrology is hiring an onsite Nurse Navigator to serve as Renal Care Associates’ clinical presence in assigned hospitals in the Peoria, Illinois area. The position is hybrid, working remotely and at practice partner offices and assigned hospitals. The Nurse Navigator identifies Evergreen-aligned patients early in hospitalization, engages patients and caregivers, collaborates with hospital teams on discharge readiness, and coordinates a closed-loop transition to home or a post-acute setting. The role works with the patient’s nephrologist and other members of the care team, as well as Evergreen Care Management teams, to reduce avoidable readmissions and prolonged post-acute stays.

This is a transitional role rather than longitudinal care after handoff, except for appropriate follow-up with patients discharged to skilled nursing facilities. The Nurse Navigator supports safe, patient-centered transitions, including education, medication reconciliation, assessment of social and clinical barriers, follow-up coordination, and warm handoffs to Evergreen care management. The role also contributes to program reporting and process improvement, and builds relationships with hospital, practice, post-acute, and community partners.

Requirements

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• At least 3–5 years of clinical nursing experience.
• Experience in one or more of the following: hospital case management, care coordination, hospital nursing, transitional care management, population health, nephrology, home health, or post-acute care.
• Strong understanding of acute-care discharge-planning processes.
• Ability to travel locally between assigned facilities based on program and patient needs.
• Experience collaborating with interdisciplinary care teams.
• Strong communication, relationship-building, and patient-education skills.
• Strong critical-thinking, problem-solving, and organizational abilities.
• Intermediate proficiency with Microsoft Office Suite, including Outlook and Teams.
• Ability to work independently in a hospital-based environment while remaining closely connected to Evergreen.
• Ability to obtain and maintain hospital credentialing, badging, and required health clearances.
• Comfort working with hospital census, referral, and patient-identification workflows.
• Ability to work effectively in a hybrid environment. Home internet must support at least 25 Mbps download and 10 Mbps upload; hardwired cable, fiber, or DSL connections are recommended.
• Employees must work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information.
• Bachelor of Science in Nursing (BSN) is preferred.

Nice To Haves

• Bachelor of Science in Nursing (BSN).

Responsibilities

• Identify RCA/Evergreen patients during inpatient admissions through hospital census review, referrals, and Evergreen ADT feeds.
• Identify patients who may safely transition home or with home health rather than enter a post-acute facility, and work with patients, caregivers, and hospital teams to address barriers while respecting patient choice.
• Conduct bedside assessments of clinical, psychosocial, caregiver, and discharge-planning needs.
• Build trusted relationships with patients and caregivers and provide education and support throughout hospitalization.
• Collaborate with physicians, case managers, social workers, utilization management teams, discharge planners, and other interdisciplinary team members to support safe transitions.
• Promote home-based care and home health services when clinically appropriate.
• For patients discharged to skilled nursing facilities, provide short-term transition follow-up, confirm the discharge plan and target date, identify stalled progress, escalate changes in condition, support return-home planning, and complete handoffs to Evergreen Care Management when indicated.
• Support medication reconciliation, identify medication-related risks or barriers, and confirm patient understanding of the discharge medication plan.
• Assess social determinants of health and identify barriers that may increase readmission risk or lead to poor outcomes.
• Work with hospital case management to ensure nephrology, primary care, and specialty follow-up is scheduled and clearly handed off before discharge.
• Confirm the immediate post-discharge plan, including medications, home health services, durable medical equipment, transportation, follow-up appointments, and handoff to Evergreen Care Management as appropriate.
• Support enrollment in Evergreen care management and clinical programs through warm handoffs and transition planning.
• Follow patients through post-acute settings, including skilled nursing facilities, to support continuity of care.
• Participate in interdisciplinary rounds, care conferences, and discharge-planning meetings.
• Maintain timely and accurate documentation in designated systems.
• Collect and report program metrics, patient outcomes, and utilization data.
• Support process-improvement initiatives to enhance care transitions, reduce readmissions, and optimize post-acute outcomes.
• Build and maintain relationships with hospital leadership, care coordination departments, nephrology practices, and community partners.
• Perform other duties consistent with the role, as assigned.

Benefits

• Paid time off starting at four weeks for full-time employees.
• 12 paid holidays per year.
• Medical, dental, vision, and life insurance.
• Health savings account (HSA) with employer match.
• Continuing medical education reimbursement for eligible roles.
• 401(k) program with an employer match of up to 4% of contributions after six months of tenure.
• Paid parental leave.
• Training and development program beginning with onboarding and continuing throughout employment.
• Quarterly bonus eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level