Nurse Navigator (RN)

Evergreen Nephrology • Peoria, IL

5d • $90,000 - $105,000 • Hybrid

About The Position

Evergreen Nephrology is hiring an Onsite Nurse Navigator to serve as Renal Care Associates’ clinical presence within assigned hospitals in the Peoria, Illinois area. The position is hybrid, with work performed remotely and at practice partner offices and assigned hospitals. The Nurse Navigator helps manage transitions from hospitalization to a safe return home or successful placement in a post-acute setting, such as a skilled nursing facility.

The role identifies Evergreen-aligned patients early in their hospitalization, engages patients and caregivers, collaborates with hospital care teams on discharge readiness, and addresses gaps that could contribute to avoidable readmissions or prolonged post-acute stays. The Nurse Navigator owns the closed-loop transition plan in collaboration with the patient’s nephrologist and other relevant specialists, primary care providers, and Evergreen Care Management teams. This is a transitional role and does not provide longitudinal care after handoff, except for appropriate follow-up with patients discharged to skilled nursing facilities.

The position calls for an RN comfortable collaborating across care settings, influencing discharge planning, and building trusted relationships with hospital teams, post-acute providers, patients, and families. The Nurse Navigator also contributes to quality improvement and program reporting. Compensation is $90,000 to $105,000 annually, with eligibility for a quarterly bonus.

Requirements

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• Minimum of 3–5 years of clinical nursing experience.
• Experience in at least one 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.
• Excellent 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 and effectively 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.
• Must work from a dedicated space without ongoing interruptions to protect member PHI and HIPAA information.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

• Identify Renal Care Associates and Evergreen Nephrology patients during inpatient admissions through hospital census review, referrals, and Evergreen ADT feeds.
• Identify patients who may be able to transition safely 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 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
• Education Level: No Education Listed