Care Manager - Registered Nurse
About The Position
Monogram Health is seeking a Registered Nurse to serve as a key member of an integrated care team that includes an Advanced Practice Provider and a Social Worker. The Care Manager RN supports patients with multiple serious and chronic diseases, helping improve their quality of life at home and slow the progression of kidney disease. The role works with a small panel of patients and builds trusting relationships while keeping patients and their long-term quality of life at the forefront of care. The nurse coordinates care with patients’ medical providers, performs in-home visits and health assessments, monitors biometric information, supports medication and treatment adherence, and educates patients and their families. The position also helps patients navigate transitions after surgery or hospital discharge and coordinates with dialysis providers. Frequent local travel is required for home visits, and infrequent domestic travel may be needed, primarily to Brentwood, Tennessee, for training. The role may include remote on-call coverage on some nights and weekends.
Requirements
- Graduate of an accredited School of Nursing.
- Current Registered Nurse license in the state of the posted location.
- Basic Life Support (BLS) certification for Healthcare Providers.
- At least 2 years of previous experience in care management and/or working with CKD/ESRD patients.
- Ability to work independently with minimal supervision.
- Ability to demonstrate empathy and quickly build relationships with patients and physicians.
- Excellent verbal communication skills, in person and by phone.
- Familiarity with Microsoft Office and mobile phone and web-based applications.
- Ability to take remote call on some nights and weekends.
- Ability to travel locally frequently for in-home visits.
Responsibilities
- Work with patients’ medical providers to develop and continually adapt care plans.
- Perform in-home care management visits to carry out care plans.
- Monitor biometric data and follow approved protocols for necessary interventions.
- Inventory and reconcile medications and coordinate with pharmacists and prescribers.
- Perform patient health assessments and surveys as required.
- Provide individual and group education on CKD, ESRD, dialysis, and associated comorbidities.
- Encourage medication and treatment adherence through frequent patient contact.
- Engage patients’ families and social support groups in patient education and care.
- Serve as the primary point of contact during business hours for patients’ questions.
- 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 modalities.
- Obtain vital signs during patient visits and escalate concerns to the provider.
- Initiate patient relationships through enrollment and onboarding.
- Perform post-operative and hospital-discharge visits to support patients through vulnerable transitions.
- Review and document patient updates and progress in the care management platform.
- Coordinate with dialysis providers to support seamless transitions of care.
Benefits
- Medical, dental, and vision insurance.
- Employee assistance program.
- Employer-paid and voluntary life insurance.
- Disability insurance.
- Health and flexible spending accounts.
- 401(k) with employer match.
- Financial wellness resources.
- 20 PTO days, 7 paid holidays, and 1 floating day.
- Paid parental leave.
- Work-life assistance resources.
- Physical wellness perks.
- Mental health support.
- Employee referral program.
- BenefitHub employee discounts.
- Bonus opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
