Inpatient Care Manager – Atlanta GA at Monogram Health
Description
The Inpatient Care Manager reports directly to the Market Physician Executive (MPE) within their Pod and is responsible for engaging with Monogram’s attributed patients and their families in inpatient facilities. The role’s primary responsibility is to find, engage and enroll new patients in the Monogram program, while also visiting currently enrolled patients who are hospitalized and providing support with discharge planning or social services. Occasionally, the manager may perform these activities in outpatient settings such as dialysis centers or primary care clinics. The position requires empathy, inquisitiveness and resourcefulness to identify and solve for each patient’s unique needs. The manager coordinates with hospital or payer staff to gain access and meets daily concurrent review rounds to stay apprised of newly admitted patients, building a daily work queue and maintaining relationships with the MPE, Market Administrative Coordinator (MAC) and Clinical Performance Lead (CPL).
Roles and Responsibilities
Attends daily concurrent review rounds with Pod clinical leaders and works with their manager to build a daily work queue
Reviews inpatient and emergency room admission data through Monogram’s care events
Conducts pre‑visit research to better understand each patient’s background and potential needs
Drives to and finds patients in facilities to engage with them and facilitate enrolling them in the Monogram program
Assesses patient’s cognitive status to ensure effective communication, and verifies patient identification and contact details for HIPAA compliance
Articulates Monogram’s services and value in an accurate and compelling manner, while respecting boundaries of the patient and family
Ability to engage and build rapport with patients, family and caregivers of diverse socio‑economic and cultural backgrounds with multiple chronic conditions and vulnerabilities
Applies evidence‑based criteria to determine clinical intervention eligibility and recommend next actions to Pod leadership, as needed
Identifies social services and discharge planning needs and works with the patient, family and hospital staff to access resources
Serves as an informational resource for patients and families/caregivers regarding their care plan and available services (hospice care, palliative care, long‑term acute care, home care, etc.)
Evaluates patient’s progress and effectiveness of resources or services, making necessary and appropriate changes based upon patient’s status
Reviews patient consent status and obtains new consent, if required
Practices within the scope of licensure
Position Requirements
Graduate from an accredited Social Worker or Registered Nurse program of study
Current active Social Worker or Registered Nurse (unrestricted) licensure
Minimum of two (2) years’ previous care management experience
Ability to demonstrate empathy, compassion, and quickly build relationships with patients, family/caregivers, and care teams, including physicians
Ability to handle rejection and keep trying, while respecting patient’s and families’ boundaries
Ability to navigate hospital environments, advocate for access and maintain composure when faced with resistance from hospital staff
Experience assessing vulnerable high‑risk patients and advocating for their needs to external staff at hospitals or payers
Demonstrated verbal and written communication skills
Previous experience with electronic health record platforms, MS Office Suite, and mobile phone and web‑based applications
Reliable personal transportation, valid driver’s licence, and auto insurance
Must live in the desired geography and be willing to travel 2‑3 hours per day to visit patients
Ability to work independently with minimal supervision as well as part of a team
Demonstrated initiative and self‑starter
Infrequent domestic travel may be required, primarily to Brentwood, TN
Benefits
Opportunity to work in a dynamic, fast‑paced, and innovative care management company that is transforming the delivery of kidney care.
Competitive salary and opportunity to participate in company’s bonus program.
Comprehensive medical, dental, vision and life insurance
Flexible paid leave & vacation policy
401(k) plan with matching contributions
About Monogram Health
Monogram Health is a leading multispecialty provider of in‑home, evidence‑based care for the most complex of 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; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, 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 home.
Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors.
EEO Statement
At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.