Care Manager RN
1 week ago
Monogram Health is seeking a skilled Registered Nurse to join our team as a Care Manager RN. As a Care Manager RN, you will play a key role in delivering high-quality care to patients with chronic kidney and end-stage renal disease.
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 (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 patient 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 care management platform
- Coordinate with dialysis providers to ensure transitions of care are seamless
- Frequent local travel to perform in-home visits
- 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 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 seek to transform the way nephrology, primary care and chronic condition treatment is delivered. Our in-home approach utilizes a national nephrology practice supported by case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs.
By increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.
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.
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