Care Manager RN
4 days ago
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 play a vital role in improving the quality of life for our patients with chronic kidney and end-stage renal disease.
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
- Engage family and social support groups in the education and care of patients
- 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
- 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
- Graduate of an accredited School of Nursing
- 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
Monogram Health is a value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. We strive to transform the way nephrology, primary care, and chronic condition treatment is delivered, putting our patients and their quality of life at the forefront of what we do.
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