Nurse Care Coordinator for Chronic Disease Management

7 days ago


Angleton, Texas, United States Monogram Health Full time
Job Title: Nurse Care Coordinator for Chronic Disease Management

About the Role:
This position involves working closely with patients' medical providers to develop and continually adapt care plans. The successful candidate will perform in-home care management visits, monitor biometric data, and coordinate with pharmacists and prescribers.

Key Responsibilities:
  • Work with a small panel of patients to execute care management plans
  • Monitor biometric data and follow approved protocols for necessary interventions
  • Inventory and reconcile medications, coordinating 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

Requirements:
  • Frequent local travel for in-home visits
  • Infrequent domestic travel may be required for training
  • Self-starter with ability to work independently with minimal supervision
  • Empathy and ability to build relationships with patients and physicians
  • Graduate of an accredited School of Nursing and currently licensed as a Registered Nurse
  • 2+ years previous experience in care management and/or with CKD/ESRD patients

About Monogram Health:
We are a value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. Our mission is to transform the way nephrology, primary care, and chronic condition treatment is delivered. By increasing access to evidence-based care pathways and addressing social determinants of health, we aim to improve health outcomes while lowering medical costs.
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