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Job Description
Monogram Health is looking for a skilled Registered Nurse eager to make a difference in patients' lives. As a Care Manager RN, you will be a key member of an integrated Care Team that includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life at home and slow the progression of kidney disease, enabling positive health outcomes.
Your Impact
As a Registered Nurse, you are an integral part of building trusting relationships with patients, enabling them to experience a high quality of life at home. You will work with a small panel of patients where you can directly feel the impact of your care. In healthcare systems, patients are often secondary due to processes and incentives that don’t positively impact long‑term outcomes. At Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of everything we do.
Highlights & 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, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time
Responsibilities
Work closely with patients’ medical providers to develop and continually adapt care plans.
Perform in‑home care management visits to execute care plans.
Monitor biometric data and follow approved protocols for any necessary interventions.
Inventory and reconcile medications and coordinate 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 and be the first call when patients have questions (business hours).
Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices.
Educate patients and facilitate conversations about proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities.
Obtain vital signs when visiting patient and elevate any concerns to the provider.
Initiate patient relationships through enrollment and onboarding processes.
Perform post‑op and hospital discharge visits to help 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.
Position Requirements
Frequent local travel to perform in‑home visits.
Basic Life Support (BLS) certification is required. The company will support certification completion through 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.
At least 2 years of previous experience working in care management and/or with CKD/ESRD patients.
Ability to take calls 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.
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. Monogram Health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present—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 multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues, prescribe medication, provide guidance, education, and counseling, and assist with daily needs such as access to food, healthy eating, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their homes. Monogram Health’s personalized and innovative treatment model improves patient outcomes and quality of life while reducing medical costs across the health‑care continuum.