Care Manager RN

About the Role

Monogram Health is seeking a skilled Registered Nurse to join an integrated Care Team that includes an Advanced Practice Provider and a Social Worker. As a Care Manager RN, you will help patients with multiple serious diseases improve their quality of life at home and slow the progression of kidney disease, enabling positive health outcomes. You will work with a small panel of patients, directly experiencing the impact of your care and building trusting relationships to prioritize patient well-being.

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 during 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

• Frequent local travel to perform in-home visits
• Basic Life Support (BLS) certification required; company supports certification completion through onboarding
• Infrequent domestic travel, 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

• Comprehensive Benefits: Medical, dental, and vision insurance; employee assistance program; employer-paid and voluntary life insurance; disability insurance; 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 patients with multiple chronic conditions. The company takes a comprehensive and personalized approach to health, treating not only diseases but also the chronic conditions that accompany them—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 disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care. The team diagnoses and treats health issues, reviews and prescribes medication, provides guidance and education on healthcare options, and assists with daily needs such as 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.