Care Manager - Registered Nurse

Care Manager – Registered NurseMonogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes.Your Impact:As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.Roles and ResponsibilitiesThe Care Manager RN will be required to provide in-home care across a multi-region territory. While most day-to-day visits will be in the Lubbock, TX area, the RN should expect periodic travel to the Amarillo and Odessa regions as well. Typical travel may include up to one week per month, with travel expenses reimbursed per company policy.Work closely with patients' medical providers to develop and continually adapt care planPerform in-home care management visits to execute care management planMonitor biometric data and follow approved protocols for any necessary interventionsInventory and reconcile medications and coordinate with pharmacists and prescribersPerform patient health assessments and surveys as requiredDeliver individual and group education on CKD, ESRD, dialysis and associated comorbiditiesEncourage medication and treatment adherence through frequent contact with patientsEngage family and social support groups in the education and care of patientsServe 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 choicesEducate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalitiesObtain vital signs when visiting patient and escalate any concerns to the providerInitiate patient relationships through enrolment and onboarding processesPerform post-op and hospital discharge visits to help patients through vulnerable transitionsReview and document patient updates and progress in care management platformCoordinate with dialysis providers to ensure transitions of care are seamlessPosition RequirementsBilingual (English/Spanish) highly preferredFrequent local travel to perform in-home visitsBasic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboardingInfrequent domestic travel may be required, primarily to Brentwood, TN for trainingSelf-starter with the ability to work independently with minimal supervisionAbility to show empathy and quickly build relationships with patients and physiciansGraduate of an accredited School of NursingCurrently licensed as a Registered Nurse in the State of the posted location2+ years previous experience working in care management and/or with CKD/ESRD patientsAbility to take call remotely on some nights and weekendsExcellent verbal communication skills both in person and on the phoneFamiliarity with Microsoft Office and mobile phone and web-based applicationsBenefitsComprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accountsFinancial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resourcesTime Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave. 20 PTO days, 7 paid holidays, and 1 floating day to make your own.Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discountsAbout Monogram HealthMonogram 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 counseling 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.