Care Manager - Registered Nurse

Monogram Health • Virginia Beach, VA

1d • Hybrid

About The Position

Monogram Health is seeking a skilled Registered Nurse to serve as a Care Manager, a key member of an integrated Care Team alongside an Advanced Practice Provider and a Social Worker. This role focuses on making a significant difference in the lives of patients who often manage multiple serious diseases. Registered Nurses in this position help patients improve their quality of life at home and work to slow the progression of kidney disease, ultimately leading to positive health outcomes. As an integral part of building trusting relationships, the Registered Nurse will work with a small panel of patients, directly experiencing the impact of their care. Monogram Health aims to prioritize patients and their quality of life, shifting away from healthcare systems where patient needs can become secondary.

Requirements

• Frequent local travel to perform in-home visits
• Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding
• Infrequent domestic travel may be required, primarily to Brentwood, TN for training
• Self-starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and physicians
• Graduate of an accredited School of Nursing
• Currently licensed as a Registered Nurse in the State of the posted location
• 2+ years previous experience working in care management and/or with CKD/ESRD patients
• Ability to take call remotely on some nights and weekends
• Excellent verbal communication skills both in person and on the phone
• Familiarity with Microsoft Office and mobile phone and web-based applications

Responsibilities

• Work closely with patients’ medical providers to develop and continually adapt care plan
• Perform in-home care management visits to execute care management plan
• Monitor biometric data and follow approved protocols for any necessary interventions
• Inventory and reconcile medications and coordinate with pharmacists and prescribers
• Perform patient health assessments and surveys as required
• Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities
• Encourage medication and treatment adherence through frequent contact with patients
• Engage family and social support groups in the education and care of patients
• Serve 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 choices
• Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
• Obtain vital signs when visiting patient and escalate any concerns to the provider
• Initiate patient relationships through enrolment and onboarding processes
• Perform post-op and hospital discharge visits to help patients through vulnerable transitions
• Review and document patient updates and progress in care management platform
• Coordinate with dialysis providers to ensure transitions of care are seamless

Benefits

• Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
• Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources
• Time Off & Leave – Paid holidays, vacation time/PSSL, and paid parental leave
• Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 251-500 employees