Care Manager RN

4 weeks ago

Denton, Texas, United States Monogram Health Full time

About the Role:

Monogram Health is seeking a skilled Registered Nurse to join our team as a Care Manager RN. As a key member of our integrated Care Team, you will work closely with patients, medical providers, and other healthcare professionals to develop and implement personalized care plans.

Key Responsibilities:

  • Work closely with patients' medical providers to develop and continually adapt care plans
  • Perform in-home care management visits to execute care management 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
  • 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 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 care management platform
  • Coordinate with dialysis providers to ensure transitions of care are seamless

Requirements:

  • Frequent local travel to perform in-home visits
  • Infrequent domestic travel may be required, primarily 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 previous experience working 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 phone and web-based applications

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