Nurse Practitioner / Physician Assistant

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex patients who have multiple chronic conditions. We take a comprehensive and personalized approach to health, treating not only 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, transportation, and financial assistance. Monogram Health is available 24/7 to support and treat patients in their homes, improving outcomes and quality of life while reducing healthcare costs.

About the Role

As an Advanced Practice Provider at Monogram Health, you will be a key member of an integrated Care Team that includes a Registered Nurse and a Social Worker. You will deliver personalized and compassionate care to patients primarily with Chronic Kidney Disease (CKD) through End-Stage Renal Disease (ESRD). This position involves traveling throughout your assigned geography to connect with patients and deliver high-impact clinical care. Your work will focus on patient health assessments, creating strategies to improve or manage health, and promoting healthy habits. The role is approximately 4 days a week driving to patient homes and 1 day working via telehealth from your home.

Responsibilities

• Counsel and educate patients and families about benefits and programs available to help them live healthier lives.
• Document items such as appropriate chief complaint, all applicable diagnoses, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan.
• Coordinate care with primary care providers, specialists, and appropriate ancillary services.
• Complete all documentation and paperwork in a timely manner.
• Maintain quality of care standards as defined by the practice.
• Deliver evidence-based, timely care to reduce avoidable hospitalizations, maximize quality of life, and prioritize patient health and satisfaction.
• Prescribe medications, order tests, and collaborate with the patient’s Monogram physician.
• Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily.
• Facilitate closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing.
• Assist patients with enrolling in educational videos.
• Participate in integrated care team meetings.
• Assess patient health status and implement a plan consistent with the appropriate plan of care.
• Follow up and evaluate patient status.
• Demonstrate knowledge of disease diagnosis and prevention.
• Other duties as assigned.

This position is not office-based but will be based in the state in which you are employed. Periodic travel outside of that state for training or meetings may be required.

Requirements

• Active and unrestricted Registered Nurse and Nurse Practitioner Board certification for appropriate licensure (NP: ANCC/AANP).
• Current and unrestricted DEA certificate, or eligibility.
• Ability to work without direct supervision and practice autonomously.
• Access to transportation, a valid driver’s license, and car insurance.
• Proficiency with medical instruments and equipment required for the role.
• Knowledge of computer-based data management programs, information systems, medical records, and point-of-interview technology.
• Ability to communicate effectively in verbal and written form with medical partners, patients, family members, physicians, and community representatives.
• Sound understanding of all federal and state regulations, including HIPAA and OSHA.
• 2 or more years of direct patient care experience.

Benefits

• 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.