Palliative Advanced Practice Provider

Monogram Health•Houston, TX

4d•Remote

About The Position

Monogram Health is seeking a full-time Palliative Care Advanced Practice Provider (APP) to support its nationwide growth. The APP will provide in-market care, primarily through in-home visits, to a highly complex patient population in the community, including end-of-life patients with CKD/ESRD, diabetes, COPD, and CHF. Virtual visits may be used as needed. Working with the Market Physician Executive, Palliative Care Lead Physician, and interdisciplinary team, the APP will provide patient-centered palliative care and clinical guidance to patients and families, including pain and symptom management, individualized care planning, advance care planning, and documentation of advance directives. The position is remote, with periodic training and meetings outside the employee’s home state. Travel within the designated region is required for in-home and clinic visits.

Requirements

Active and unrestricted Nurse Practitioner or Physician Assistant license.
Board certification appropriate to licensure: NP certification through ANCC or AANP, or PA certification through NCCPA.
Current and unrestricted DEA certificate.
At least two years of experience working with patients in a palliative care setting; other relevant experience will be considered.
Ability to work without direct supervision and practice autonomously.
Reliable transportation and ability to travel within the designated region to meet patient needs, including in-home and clinic visits.
Access to transportation, a valid driver’s license, and car insurance.
Active state-specific licensure and willingness to obtain licensure in multiple states as company and patient needs require.

Nice To Haves

Certification in ACHPN or CHPN.
Demonstrated experience in clinical assessment, care plan design, and evaluating patients using evidence-based clinical criteria.
Communication skills for sensitive conversations about prognosis and end-of-life decisions, including goals-of-care discussions and advance care planning.
Proficiency with electronic health record (EHR) systems to document complex case details.

Responsibilities

Partner with the Market Physician Executive and clinical leaders, including the Palliative Care physician, to identify eligible patients, build panels, and develop individualized, evidence-based care plans aligned with patient goals.
Deliver compassionate, patient-centered palliative care, primarily through in-home visits and virtual visits as needed.
Conduct assessments and annual wellness exams; manage symptoms such as pain, pruritus, depression, anxiety, and insomnia; and develop treatment plans.
Prescribe medications, order tests, and manage medication regimens in collaboration with pharmacists and the patient’s Monogram physician.
Conduct ongoing follow-up and evaluate patient status, adjusting care plans as needed.
Educate patients and families about disease progression, treatment options, and palliative and hospice principles.
Guide families through complex medical decisions, prognosis discussions, and advance care planning, including documenting AD/POLST forms.
Support hospice transitions when appropriate.
Coordinate care with primary care providers, specialists, ancillary services, and the interdisciplinary team, including the Palliative Care Chaplain.
Participate in integrated care team meetings and monthly clinical leadership meetings to support program KPIs.
Complete timely, comprehensive documentation, including chief complaint, diagnoses, history, ROS, examination, and assessment and plan.
Close care gaps through preventive monitoring education and diagnostic scheduling.
Meet daily-tracked quality outcome metrics.
Educate patients and families about available benefits and programs that support healthier living.
Train team members on palliative and hospice care, advance directives, symptom assessment, and communication.
Support patient enrollment in educational resources.