Care Manager RN

Monogram Health, Inc.; Atlanta, Northern (GA, KY); Hybrid; USD 68,000 - 95,000; Full time

Benefits offered by this job

Medical, dental & vision insurance

401k with employer match

Paid time off and parental leave

Job summary

Monogram Health is seeking a Care Manager – Registered Nurse to lead in-home care management for patients with chronic kidney disease and ESRD. You will work with a small panel, develop and adapt care plans with physicians, and educate patients and families to improve quality of life.

Flexible travel for local in-home visits is required. The role emphasizes empathetic patient relationships, coordination with providers, and proactive, proactive care planning within an integrated care team.

Qualifications

• RN license in the state of posting location
• BLS certification required; company supports certification during onboarding
• 2+ years in care management and/or CKD/ESRD experience
• Strong communication with patients and physicians; empathetic approach
• Ability to travel locally for in-home visits and occasional training travel

Responsibilities

• Develop and continually adapt patient care plans with medical providers
• Perform in-home care management visits and execute care plans
• Monitor biometric data and follow protocols for interventions
• Reconcile medications and coordinate with pharmacists and prescribers
• Educate patients and families on CKD/ESRD, dialysis, and associated comorbidities
• Encourage adherence through regular contact with patients
• Serve as primary point of contact for patients during business hours
• Coordinate with dialysis providers to ensure seamless transitions of care
• Complete post-op and hospital discharge visits to support transitions

Skills

In-home care management

RN license

BLS certification

Empathy

Communication skills

Independent work

Microsoft Office

Education

Graduate of an accredited School of Nursing

Tools

Microsoft Office

Job description

Job Description: Care Manager – Registered Nurse

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.

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 escalating 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
• 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 – Paid holidays, flexible vacation time/PSSL, 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 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.

Qualifications

Licenses & Certifications

Preferred

Registered Nurse

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.