Care Manager - Registered Nurse

Monogram Health; Phenix City (AL); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Flexible scheduling

Bonus program

Full benefits package

Job summary

Monogram Health is seeking a Care Manager RN to support in-home care for patients with chronic kidney disease. You will work with a care team to develop and execute individualized plans, monitor health data, and coordinate medications.

You will visit patients at home, educate on CKD/ESRD management, and collaborate with physicians to ensure smooth transitions across care settings. This role requires travel and RN licensure.

Qualifications

• Graduate of an accredited School of Nursing.
• Currently licensed as a Registered Nurse in the State of the posted location.
• 2+ years in care management and/or CKD/ESRD care.

Responsibilities

• Develop and adapt care plans with patients and providers.
• Perform in-home care management visits.
• Monitor biometric data and follow protocols.
• Coordinate medications with pharmacists and prescribers.
• Educate patients on CKD/ESRD, dialysis, and comorbidities.
• Encourage adherence through regular contact with patients.
• Engage families and social supports in care.
• Serve as primary contact during business hours.
• Educate on medications, conditions, diet, exercise, and lifestyle.
• Discuss Advance Care Plans and ESRD treatment options.
• Obtain vitals and escalate concerns to providers.
• Initiate enrollment and onboarding.
• Support transitions post-op and after hospital discharge.
• Document updates in care management platform.
• Coordinate transitions with dialysis providers.

Skills

BLS certification

Empathy

Communication

Independent work

MS Office

Education

RN licensed in state

Tools

Microsoft Office

Job description

Job Description: Care Manager – Registered Nurse

FUTURE OPPORTUNITIES in West Central Alabama

Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes 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.

Your Impact

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. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.

Highlights & Benefits

• Flexible scheduling with a hybrid and in-home model
• Competitive compensation and a performance-based bonus program
• Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time

Roles and Responsibilities

• Work closely with patients’ medical providers 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 (business hours)
• Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices
• Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
• Obtain vital signs when visiting patient and elevate any concerns to the provider
• 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

• Frequent local travel to perform in-home visits
• Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding
• Infrequent domestic travel may be required, primarily to Brentwood, TN for training
• 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

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.