Nurse Practitioner/Physician Assistant
About the role
Monogram Health is seeking compassionate and skilled Advanced Practice Providers (Nurse Practitioners or Physician Assistants) to deliver high‑quality in‑home care to patients living with multiple chronic conditions, including diabetes, hypertension, chronic kidney disease, heart failure, COPD, depression, and other complex health needs. This role works within an integrated multidisciplinary care team (Clinical, Behavioral Health, Pharmacy, Administrative), establishing long-term patient relationships and providing continuity of care to complex patients in their homes and via telehealth. The Advanced Practice Provider has the opportunity to be part of a value-based, patient-centered care model, providing quality driven managed care with a population health focus.
Responsibilities
- Provide evidence‑based, patient‑focused care that reduces avoidable hospitalizations and improves quality of life directly in the patient’s home
- Perform comprehensive assessments, including initial evaluations, annual wellness exams, follow‑ups, acute urgent visits, and post‑discharge visits.
- Educate patients and caregivers on disease management, preventive care, medications, and diagnostic testing
- Participate in recurring virtual integrated care team meetings
- Engage in quality assurance activities, including audits and documentation reviews, to ensure compliance with state board requirements and clinical best practices
- May practice in a variety of care settings beyond the patient’s home, including skilled nursing facilities (SNFs), assisted living facilities (ALFs), hospitals, and other affiliated clinical settings, as applicable.
- Perform point-of-care testing (A1C and Spi