Care Manager - Registered Nurse

Monogram Health•Olive Branch, MS

About The Position

Monogram Health is seeking a Registered Nurse to serve as a Care Manager on an integrated Care Team that includes an Advanced Practice Provider and a Social Worker. The role supports patients with multiple serious and chronic conditions, especially kidney disease, helping them improve their quality of life at home and slow disease progression. The Care Manager works with a small panel of patients and builds trusting relationships while keeping patients’ needs and long-term quality of life at the forefront of care. The position involves coordinating and adapting care plans with patients’ medical providers, conducting in-home visits and assessments, monitoring biometric data, reconciling medications, and providing education and coaching. The nurse is a primary point of contact for patients during business hours, supports adherence to treatment, coordinates transitions of care, and documents patient progress in a care management platform. Frequent local travel is required for home visits, with occasional domestic travel, primarily to Brentwood, Tennessee, for training. The role may require remote on-call coverage on some nights and weekends. The base salary range is $80,072 to $96,836. Final compensation depends on geographic location and job-related factors, including experience, skills, education, certifications, and internal compensation considerations. The role is 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 during onboarding.
Ability to take remote call on some nights and weekends.
Ability to travel frequently locally for in-home visits.
Self-starter with the 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 over the phone.
Familiarity with Microsoft Office and mobile phone and web-based applications.

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 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’ family members and social support groups in education and care.
Serve as the primary point of contact and first call for patient questions during business hours.
Educate and coach patients on 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.
Conduct 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 ensure seamless transitions of care.