Description Monogram Health is looking for a skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which 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 in the home and slow the progression of kidney disease, enabling positive health outcomes.
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 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 around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
Obtain vital signs when visiting patients and escalate any concerns to the provider
Initiate patient relationships through enrolment 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 transitions of care are seamless
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
2+ years of experience 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/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, life insurance, 401(k) with matching contributions, paid vacation and holiday time
About Monogram Health Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with multiple chronic conditions. The organization emphasizes a comprehensive and personalized approach, addressing diseases and related conditions to improve quality of life. Monogram Health operates 24/7 to support patients in their homes with a robust clinical team across nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care.