Care Manager - Registered Nurse

Monogram Health; Mesquite (TX); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

401k with employer match

Paid holidays

Paid parental leave

20 PTO days

Wellness resources

Job summary

Monogram Health is seeking a Care Manager to improve patient lives through in-home management and close collaboration with nephrologists. You will build ongoing patient relationships, guide care plans, and support transitions from hospital to home.

Ideal candidates areRNs with CKD/ESRD experience, strong communication, and the ability to work independently. This role includes occasional domestic travel and a comprehensive benefits package.

Qualifications

• Active RN license in AZ or an active license in an NLC state
• 2+ years in care management and/or CKD/ESRD patient care
• Willingness to travel domestically (occasional trips to Brentwood, TN)
• Strong verbal communication and empathy
• Ability to work independently with minimal supervision

Responsibilities

• Develop and continually adapt care plans with nephrologists
• Perform in-home care management visits
• Monitor biometric data and intervene per approved protocols
• Coordinate medications with pharmacists and prescribers
• Conduct patient health assessments and education on CKD/ESRD and dialysis
• Support transitions post-hospital discharge

Skills

Empathy

Relationship building

Verbal communication

Independent work

Care management

CKD/ESRD experience

Domestic travel

MS Office

Education

Registered Nurse (RN) license

Accredited nursing program graduate

AZ or NLC state RN license

Tools

Care management software

Telehealth platforms

Mobile/web health apps

Job description

Monogram Health Care Managers have the opportunity to improve patient lives each and every day. Care Managers build long-term meaningful relationships by working with the same small panel of patients face-to-face in the patients’ homes. In close partnership with local nephrologists and with the support of a Care Team including a Social Worker and a Care Coordinator, Care Managers lead the effort to help our patients achieve better quality outcomes and slower progression of kidney disease while reducing costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure. For those already on dialysis, our Care Managers will provide additional support particularly around transitions in care, such as hospital discharges.

Care Managers work with patients to encourage healthy behaviors and ensure patients are well informed and empowered to make proactive decisions about their own care. Tools available include a custom care management software platform, wireless biometrics, telehealth capabilities, patient-friendly education materials, and pharmacists performing regular comprehensive medication reviews. Care Managers care deeply about their patients as people and truly believe that the work they do makes a difference.

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 escalat e 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 Arizona (or other NLC state)
• 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
• Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
• Financial & Retirement Support– Competitive compensation, 401k with employer match, and financial wellness resources
• Time Off & Leave– 20 PTO days, 7 paid holidays, and 1 floating day to make your own, and paid parental leave
• Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts

About Monogram Health

Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. Monogram’s innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.

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.