Care Manager RN

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 and quality of life while 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, striving to shift the narrative in healthcare by focusing on proactive, patient-centered care.

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 patient contact.
• Engage family and social support groups in patient education and care.
• Serve as the primary point of contact for patients during business hours.
• Provide education and coaching on medications, medical conditions, diet, exercise, and lifestyle choices.
• Facilitate conversations around proactive care decisions, including Advance Care Plans and ESRD treatment modalities.
• Obtain vital signs during patient visits and escalate concerns to providers.
• Initiate patient relationships through enrollment and onboarding processes.
• Perform post-op and hospital discharge visits to support patients through transitions.
• Review and document patient updates and progress in the care management platform.
• Coordinate with dialysis providers to ensure seamless transitions of care.

Requirements

• Frequent local travel to perform in-home visits.
• Basic Life Support (BLS) certification is required; the company will support certification completion during 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 of 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

• Flexible scheduling with a hybrid and in-home model.
• 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.