Care Manager - Registered Nurse

Monogram Health•Willingboro Twp, NJ

About The Position

Monogram Health is seeking a skilled Registered Nurse to serve as a Care Manager and help patients improve their 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 serves patients who often have multiple serious diseases. The Care Manager builds trusting relationships with a small panel of patients and provides in-home, evidence-based care focused on patients’ long-term health and quality of life. The position involves coordinating care with patients, families, medical providers, pharmacists, prescribers, and dialysis providers. Care Managers provide assessments, education, coaching, medication support, and care-transition assistance, and document patient progress in a care management platform. The role requires frequent local travel for home visits and may involve remote call coverage on some nights and weekends, as well as infrequent domestic travel, primarily to Brentwood, Tennessee, for training. The base salary range is $95,530 to $114,636. Compensation is determined by geographic location and job-related factors, and 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.
Basic Life Support (BLS) certification for Healthcare Providers is required.
At least 2 years of previous experience working in care management and/or 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 on the phone.
Familiarity with Microsoft Office and mobile-phone and web-based applications.
Frequent local travel for in-home visits.
Ability to take remote call on some nights and weekends.

Nice To Haves

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

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.
Deliver individual and group education on CKD, ESRD, dialysis, and associated comorbidities.
Encourage medication and treatment adherence through frequent patient contact.
Engage family members and social support groups in patient education and care.
Serve as the primary point of contact during business hours for patients’ questions.
Educate and coach patients about medications, medical conditions, diet, exercise, and lifestyle choices.
Educate patients and facilitate discussions 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.