Care Manager Registered Nurse
About Monogram Health
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with multiple chronic conditions. We take a comprehensive and personalized approach to health, treating not only individual diseases but all chronic conditions present—such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Our robust clinical team leverages specialists across disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues, review and prescribe medication, provide guidance and education, and assist with daily needs like access to food, healthy eating, transportation, financial assistance, and more. Monogram Health is available 24/7 to support and treat patients in their homes, improving outcomes, quality of life, and reducing medical costs.
About the Role
As a Care Manager RN, you are a key member of an integrated Care Team that includes an Advanced Practice Provider and a Social Worker. You will work with a small panel of patients, building trusting relationships to directly impact their quality of life at home. Monogram Health prioritizes patients and their long-term well-being, focusing on slowing the progression of kidney disease and enabling positive health outcomes. You will serve as the primary point of contact for patients during business hours and help them navigate their care with empathy and expertise.
Responsibilities
- Work closely with patients’ medical providers to develop and continually adapt care plans.
- Perform in-home care management visits to execute the care management plan.
- Monitor biometric data and follow approved protocols for necessary interventions.
- Inventory and reconcile medications, coordinating 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 for patients during 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 during patient visits and escalate concerns to the provider.
- Initiate patient relationships through enrollment and onboarding processes.
- Perform post-op and hospital discharge visits to support patients through vulnerable transitions.
- Review and document patient updates and progress in the care management platform.
- Coordinate with dialysis providers to ensure seamless transitions of care.
Requirements
- Graduate of an accredited School of Nursing.
- Currently licensed as a Registered Nurse in the state of the posted location.
- 2+ years of previous experience working in care management and/or with CKD/ESRD patients.
- Basic Life Support (BLS) certification is required; the company will support certification completion through onboarding.
- Frequent local travel to perform in-home visits.
- Infrequent domestic travel may be required, primarily to Brentwood, TN for training.
- Ability to take call remotely on some nights and weekends.
- Self-starter with the ability to work independently with minimal supervision.
- Excellent verbal communication skills, both in person and on the phone.
- Familiarity with Microsoft Office and mobile phone and web-based applications.
- Ability to show empathy and quickly build relationships with patients and physicians.
Benefits
- Competitive compensation and a performance-based bonus program.
- Full benefits package including medical, dental, vision, and life insurance.
- 401(k) plan with matching contributions.
- Paid vacation and holiday time.