Job Description
Position: Care Manager - Registered Nurse
As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. At Monogram Health, our mission is to transform the way health care is delivered for those with kidney disease so they can lead healthier, happier, and more fulfilling lives. This transformation is urgently needed. In our healthcare system, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. The Care Manager - RN is a key member of an integrated Care Team which includes a an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes.
Roles and Responsibilities
Work closely with patients’ nephrologists to develop and continually adapt care plan
Perform in-home care management visits to execute care management plan
Monitor biometric data and follow approved protocols for any necessary interventions
Inventory and reconcile medications and coordinate with pharmacists and prescribers
Perform patient health assessments and surveys as required
Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities
Encourage medication and treatment adherence through frequent contact with patients
Engage family and social support groups in the education and care of patients
Serve as the primary point of contact and be the first call when patients have questions
Provide education and coaching around diet, exercise, and lifestyle choices
Educate patients and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
Obtain vital signs when visiting patient and escalate any concerns to the nephrologist
Facilitate nephrologist contact with other physicians to ensure comorbidities are managed
Initiate patient relationships through enrolment and onboarding processes
Perform post-op and hospital discharge visits to help patients through vulnerable transitions
Review and document patient updates and progress in care management platform
Coordinate with dialysis providers to ensure transitions of care are seamless
Position Requirements
Infrequent domestic travel may be required, primarily to Brentwood, TN
Self-starter with the ability to work independently with minimal supervision
Ability to show empathy and quickly build relationships with patients and physicians
Graduate of an accredited School of Nursing
Currently licensed as a Registered Nurse in the State of the posted location
2+ years previous experience working in care management and/or with CKD/ESRD patients
Ability to take call remotely on some nights and weekends
Excellent verbal communication skills both in person and on the phone
Familiarity with Microsoft Office and mobile phone and web-based applications
Benefits
Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care
Competitive salary
Comprehensive medical, dental, vision and life insurance
Flexible paid leave and vacation policy
401(k) plan with matching contributions
About Monogram Health
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.
Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.
Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024’s No. 3 fastest growing private company in the United States, please visit here.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Job Tags
Holiday work, Remote job, Flexible hours, Night shift, Weekend work,