Position: Market Physician Executive (MPE) - Float Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health’s Multi[1]Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk[1]based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population healthoutcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution – 25% Know, understand, and deliver on Monogram Health’s proprietary evidenced based clinical pathways. Ensure adherence to established clinical guidelines and Monogram Model of Care. Review and approve APP, RN, SW and PharmD plans of care. Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. Review, approve and co-sign APP encounters. Clinical and Operations Performance and Quality Improvement – 25% Overall accountability for reducing total cost of care and Medical Loss Ratio. Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure Actively lead daily high risk and concurrent review rounds. Direct supervision of front line clinical and operations team members. Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment – 25% Provide direct and indirect patient care (including diagnosis and treatment of disease). Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. Conduct Peer to Peers with community, facility, and health plan partners. Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) – 20% Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete quality post hospital discharge visits, and improving the quality of visits. Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. Present and guide population health strategies in clinical and operational meetings. Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous –
Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first Prescribe medications, order tests, and collaborate with patient’s Monogram physician Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Develop treatment plan Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) Current and unrestricted DEA certificate Ability to work without direct supervision and practice autonomously Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required Managed Care/IPA/Health Plan experience Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home About Monogram Health Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. #LI-MD1
Job Description: Care Manager – Registered Nurse Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact: As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Roles and 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 Position 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 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, flexible 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 About Monogram Health Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. #LI-MD1
Job Description: Care Manager – Registered Nurse Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact: As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Competitive compensation and a performance-based bonus program Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time Roles and 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 Position 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 About Monogram Health: Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024’s No. 3 fastest growing private company in the United States, please visit here . #LI-CP1
Job Description: Nurse Practitioner / Physician Assistant Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Flexible scheduling with a hybrid and in-home mode Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first Prescribe medications, order tests, and collaborate with patient’s Monogram physician Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Develop treatment plan Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Bilingual (English/Spanish) highly preferred Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) Current and unrestricted DEA certificate Ability to work without direct supervision and practice autonomously Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required Managed Care/IPA/Health Plan experience Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home About Monogram Health Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. #LI-JE1
