Care Manager - Registered Nurse

Monogram Health•Fort Oglethorpe, GA

6d•$80,072 - $96,836

About The Position

Monogram Health is seeking a skilled Registered Nurse to serve as a Care Manager and help improve patients’ quality of life at home while slowing the progression of kidney disease. The role is part of an integrated Care Team that includes an Advanced Practice Provider and a Social Worker, and supports patients with multiple serious conditions. Care Managers work with a small panel of patients and build trusting relationships through personalized care and frequent contact. The Care Manager collaborates with patients’ medical providers to develop and adapt care plans, conducts in-home visits, monitors patient health information, coordinates medications and transitions of care, and provides education and coaching. The role is the primary point of contact for patients during business hours and includes occasional remote call coverage on some nights and weekends. Frequent local travel is required for home visits; infrequent domestic travel may also be required, primarily to Brentwood, Tennessee, for training. The position offers a base salary range of $80,072 to $96,836, with final compensation based on factors including location, experience, skills, education, certifications, and internal compensation considerations. The role is also eligible for bonus opportunities and a comprehensive benefits package.

Requirements

Graduate of an accredited School of Nursing.
Currently licensed as a Registered Nurse in the state of the posted location.
At least 2 years of previous experience working in care management and/or with CKD/ESRD patients.
Basic Life Support (BLS) certification is required; the company supports completion of certification during onboarding.
Ability to travel locally frequently to conduct in-home visits.
Ability to take remote call on some nights and weekends.
Ability to work independently with minimal supervision.
Empathy and ability to build relationships quickly with patients and physicians.
Excellent verbal communication skills, in person and by phone.
Familiarity with Microsoft Office and mobile phone and web-based applications.

Nice To Haves

Infrequent domestic travel may be required, primarily to Brentwood, Tennessee, for training.

Responsibilities

Work with patients’ medical providers to develop and continually adapt care plans.
Conduct in-home care management visits to carry out care 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.
Provide individual and group education on CKD, ESRD, dialysis, and related comorbidities.
Encourage medication and treatment adherence through frequent patient contact.
Engage patients’ families and social support groups in education and care.
Serve as the primary point of contact for patients and respond to their questions during business hours.
Coach and educate patients about medications, medical conditions, diet, exercise, and lifestyle choices.
Educate patients and facilitate conversations about proactive care decisions, including Advance Care Plans and ESRD treatment options.
Obtain vital signs during patient visits and escalate concerns to the provider.
Initiate patient relationships through enrollment and onboarding.
Conduct post-operative and hospital-discharge visits to support patients during transitions.
Review and document patient updates and progress in the care management platform.
Coordinate with dialysis providers to support seamless transitions of care.