Care Manager - Registered Nurse

Care Manager – RNMonogram Health Care Managers have the opportunity to improve patient lives each and every day. Care Managers build long-term meaningful relationships by working with the same small panel of patients face-to-face in the patients' homes. In close partnership with local nephrologists and with the support of a Care Team including a Social Worker and a Care Coordinator, Care Managers lead the effort to help our patients achieve better quality outcomes and slower progression of kidney disease while reducing costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure. For those already on dialysis, our Care Managers will provide additional support particularly around transitions in care, such as hospital discharges.Care Managers work with patients to encourage healthy behaviors and ensure patients are well informed and empowered to make proactive decisions about their own care. Tools available include a custom care management software platform, wireless biometrics, telehealth capabilities, patient-friendly education materials, and pharmacists performing regular comprehensive medication reviews. Care Managers care deeply about their patients as people and truly believe that the work they do makes a difference.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.The base salary range for this role is $80,072 to $96,836 and reflects the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While a larger range is posted, most offers will typically fall within a narrower band based on these factors. In addition to base salary, this role is eligible for additional compensation, including bonus opportunities and a comprehensive benefits package.Roles and ResponsibilitiesWork closely with patients' nephrologists 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 questionsProvide education and coaching around diet, exercise, and lifestyle choicesEducate patients and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placementObtain vital signs when visiting patient and escalate any concerns to the nephrologistFacilitate nephrologist contact with other physicians to ensure comorbidities are managedInitiate 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 RequirementsInfrequent domestic travel may be required, primarily to Brentwood, TNSelf-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 Texas (or other NLC state)2+ 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 – 20 PTO days, 7 paid holidays, and 1 floating day to make your own, and paid parental leaveWellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts.About Monogram HealthMonogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater 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.