Care Manager - Registered Nurse

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-SJ1

Share this job

Related Jobs

Pediatric

Full-time

3 months ago

Pediatric Registered Nurse (RN), Inpatient (Nights)

Shriners Children's Greenville, SC

Company Overview Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families. All employees are eligible for medical coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law. Shriners Children’s Greenville is where hope and healing meet. Shriners Children's Greenville is a 50 bed, 250 employee, inpatient facility with two surgical suites, an outpatient clinic, in-house Pediatric Orthotics and Prosthetic Services (POPS), and Motion Analysis Center. SCG is located on the campus of Prisma Health Greenville Memorial Hospital. SCG has been recognized by community vote as “Best in the State” for Best Hospital, Best Pediatric Clinic, Best Orthopedics Center, and Best Place to Work. Our compassionate, respected physicians and staff provide care for children with a range of orthopedic and neuromuscular conditions. Our services extend to a number of outpatient clinics in both North and South Carolina, to ensure children and families throughout our region have access to high-quality pediatric care. Job Overview Are you looking for a new nursing opportunity where you can feel the difference you make in patients' lives? We have an opportunity for a full-time Pediatric Registered Nurse on our Inpatient Unit. This position will cover 12-hour night shifts and will have weekend and holiday assignments as well. Our Inpatient Services Unit consistently ranks in the highest percentiles for patient satisfaction, and your nursing expertise will contribute meaningfully to the lives of our pediatric orthopedic patients and their families. Additionally, you will be joining a stellar team of healthcare professionals made up of colleagues, orthopedic surgeons and leadership who are simply the best in their professions. Shriners Children's Greenville may be the best career decision you make this year. We can't wait to work with you! Responsibilities The Pediatric RN is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Shriners Hospitals for Children Professional Practice Model (FOCUSED), which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal and formal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability and availability of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned. Qualifications Required RN license in state of practice Basic Life Support (BLS) PALS (obtain within 1 year of employment) Preferred BSN 2 years of Pediatric and/or orthopedic experience

Pediatric

Full-time

4 months ago

Pediatric Registered Nurse (RN), Inpatient (Nights)

Shriners Children's Greenville, SC

Pediatric

Full-time

5 months ago

Pediatric Registered Nurse (RN), Inpatient (Nights)

Shriners Children's Greenville, SC

Company Overview Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families. All employees are eligible for medical coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law. Job Overview Are you looking for a new nursing opportunity where you can feel the difference you make in patients' lives? We have an opportunity for a full-time Pediatric Registered Nurse on our Inpatient Unit. This position will cover 12-hour night shifts and will have weekend and holiday assignments as well. Our Inpatient Services Unit consistently ranks in the highest percentiles for patient satisfaction, and your nursing expertise will contribute meaningfully to the lives of our pediatric orthopedic patients and their families. Additionally, you will be joining a stellar team of healthcare professionals made up of colleagues, orthopedic surgeons and leadership who are simply the best in their professions. Shriners Children's Greenville may be the best career decision you make this year. We can't wait to work with you! Responsibilities The Pediatric RN is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Shriners Hospitals for Children Professional Practice Model (FOCUSED), which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal and formal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability and availability of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. Qualifications Required RN license in state of practice Basic Life Support (BLS) PALS (obtain within 1 year of employment) Preferred BSN 2 years of Pediatric and/or orthopedic experience

Registered Nurse (RN) - Outpatient, Prep & Recovery, Full Time, Day

Prisma Health Easley, SC

Inspire health. Serve with compassion. Be the difference. Job Summary Provides clinical direction for all aspects of patient care in an outpatient setting. Demonstrates clinical competency utilizing evidence-based practices/research in all areas of the nursing process: assessment, planning, implementation, evaluation and outcomes. Incorporates knowledge of safety protocols, cost containment and quality improvement throughout the nursing process. Identifies patient, unit, and organizational priorities and incorporates into the nursing process. Adheres to all compliance and policy and procedure requirements of the organization including, but not limited to licensure renewal, assigned training, employee health screenings, time and attendance policy, dress code policy, patient confidentiality, infection control, medication administration. Demonstrates knowledge of regulatory agency requirements (JCAHO, DHEC). Provides care within the scope of the SC Nursing Practice Act. The outpatient setting usually does not require staff to be scheduled for a significant amount of shift, weekend, holiday, and on-call work. Bonus This position is bonus eligible, follow this link for details. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Collects data and completes nursing assessment utilizing appropriate area and/or age specific standards/policies and tools. Completes appropriate forms. Assesses and recognizes subtle or actual changes in patients' status and patient response to intervention. Identifies nursing priorities for patient plan of care based on nursing assessment (and other data as appropriate). Validates these priorities with healthcare team members and documents appropriately. Develops an individual plan of care based on the age and assessed needs of the patient. Develops the plan in collaboration with the patient and/or family, the physician, and other members of the interdisciplinary health care team. Updates the plan based on changes in the patient's condition and communicates changes in the plan to other members of the team. Identifies realistic and measurable goals and outcomes to be attained prior to discharge. Validates these with the patient and/or family. Demonstrates respect for the patient's/family's cultural, spiritual, and belief system in planning for care. Includes planning for discharge to assure continuity of care and a smooth transition post discharge from one level of care to another (to include appropriate referrals). Provides direct care to assigned patients consistent with the established nursing plan. Performs specific tasks based on organizational, departmental and/or unit policies and procedures within the RN scope of practice. Delegates nursing tasks as appropriate to members of the healthcare team, developing written assignments (if appropriate) and ensures completion of assigned tasks. Monitors quality of care delivered on a continual basis; ensures appropriate surveillance of assigned patients. Provides care based on patient and unit priorities, coordinating and organizing tasks as appropriate, utilizing known resources internal and external to the unit. Incorporates cost containment principles into nursing care. Assumes responsibility for patient safety by maintaining a safe environment to include awareness of safety procedures, protocols and adherence to patient care standards. Utilizes appropriate technology in daily practice. Utilizes performance indicators to collect data, monitor quality and effectiveness while providing nursing care. Completes assigned hospital/unit performance improvement monitoring (audits). Evaluates nursing plan of care for effectiveness and determines progress toward expected outcomes. Revises diagnosis, outcomes and plan of care based on evaluation of data. Reports changes in patient status and refers unresolved problems to appropriate health team members. Discusses outcomes with peers via shift-to-shift report and with other healthcare team members as appropriate. Evaluates opportunities for quality improvement and based upon evaluation, incorporates PI recommendation into nursing plan of care as appropriate. Identifies/assesses patient/family learning needs and teaches accordingly by using language and terminology that the patient/family is familiar with providing examples to clarify ideas, implementing and evaluating teaching plan (encourages patient/family, involvement/participation) Communicates the patient/family's need for education/teaching to others in the healthcare continuum. Evaluates own nursing practice in relation to professional practice standard guidelines, state statutes, family policies, procedures, rules and regulations and current specific knowledge. Maintains competency through education and professional activities. Reflects on identified areas of strength that offer opportunity for improvement. Performs other duties as assigned. Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive. Minimum Requirements Education - Associate degree in Nursing. Bachelor's degree in Nursing preferred. Experience - One (1) year experience as a registered nurse. In Lieu Of In lieu of 1 year of registered nurse experience, will accept successful completion of the Prisma Health Nurse Residency Program or successful completion of a comparable residency from another organization. In lieu of one (1) year of registered nurse experience, will accept 1 year of licensed practical nurse (LPN) experience for internal candidates within the same service line. In lieu of Associate degree in nursing, will accept nursing diploma with licensure to practice as a registered nurse. Required Certifications, Registrations, Licenses Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working. Knowledge, Skills and Abilities Basic computer skills Mathematical skills Working knowledge of Patient Equip (vitals, suction, defib) Work Shift Day (United States of America) Location Baptist Easley Med Campus Facility 1015 Baptist Easley Hospital Department 10156161 Prep & Recovery Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.

Registered Nurse (RN) - Acute Care, Med/Surg/Tele, Full Time, Day

Prisma Health Easley, SC

Inspire health. Serve with compassion. Be the difference. Job Summary Provides clinical direction for all aspects of patient care in an acute inpatient setting, fostering patient/family centered care. Demonstrates clinical competency utilizing evidence-based practices/research in all areas of the nursing process: assessment, planning, implementation, evaluation and outcomes. Incorporates knowledge of safety protocols, cost containment and quality improvement throughout the nursing process. Identifies patient, unit and organizational priorities and incorporates into the nursing process. Adheres to all compliance and policy/procedures of the organization including, but not limited to licensure renewal, assigned training, employee health screenings, time and attendance policy, dress code policy, patient confidentiality, infection control, medication administration. Demonstrates knowledge of regulatory agency requirements (TJC, SC DPH, CMS). Provides care within the scope of the South Carolina Nurse Practice Act. The acute inpatient setting may require staff to be scheduled for a weekend, holiday, and on-call work. Bonus This position is bonus eligible, follow this link for details. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Collects data and completes nursing assessment utilizing appropriate area and/or age specific standards/policies and tools. Completes appropriate forms. Assesses and recognizes subtle or actual changes in patients' status and patient response to intervention. Identifies nursing priorities for patient plan of care based on nursing assessment and other data as appropriate. Validates these priorities with healthcare team members and documents appropriately. Develops an individual plan of care based on the age and assessed needs of the patient. Develops the plan in collaboration with the patient and/or family, the provider, and other members of the interdisciplinary health care team. Updates the plan based on changes in the patient's condition and communicates changes in the plan to other members of the team. Identifies realistic and measurable goals and outcomes to be attained prior to discharge. Validates these with the patient and/or family. Demonstrates respect for the patient's/family cultural, spiritual, and belief system in planning for care. Includes planning for discharge to assure continuity of care and a smooth transition post discharge from one level of care to another including appropriate referrals. Provides direct care to assigned patients consistent with the established nursing plan. Performs specific tasks based on organizational, departmental and/or unit policies and procedures within the RN scope of practice. Delegates nursing tasks as appropriate to members of the healthcare team, developing written assignments (if appropriate) and ensures completion of assigned tasks. Monitors quality of care delivered on a continual basis; ensures appropriate surveillance of assigned patients. Provides care based on patient and unit priorities, coordinating and organizing tasks as appropriate, utilizing resources internal and external to the unit. Incorporates cost containment principles into nursing care. Utilizes appropriate technology in daily practice. Assumes responsibility for patient safety by maintaining a safe environment to include awareness of safety procedures, protocols and adherence to patient care standards. Utilizes performance indicators to collect data, monitor quality and effectiveness while providing nursing care. Completes assigned hospital/unit performance improvement monitoring (audits). Based on assessment/reassessment of patient response to interventions, evaluates plan of care for effectiveness, documents progress toward expected outcomes, and revises plan of care as needed. Reports changes in patient condition and refers unresolved problems to appropriate healthcare team members. Discusses outcomes with peers (via shift-to-shift report) and with other healthcare team members. Evaluates opportunities for quality improvement; based upon evaluation, incorporates performance improvement recommendations into the plan of care as appropriate. Identifies/assesses patient/family learning needs and teaches accordingly by using language and terminology that the patient/family is familiar with providing examples to clarify ideas, implementing and evaluating teaching plan (encourages patient/family involvement/participation), Computer resources and Micromedex utilization Communicates the patient/family's need for education/teaching to others in the healthcare continuum. Evaluates own nursing practice in relation to professional practice standard guidelines, state statutes, policies, procedures, rules/regulations and current specific knowledge. Takes personal accountability for maintaining competency through education and professional activities. Maintains professional licensure and completes required mandatory education in a timely manner. Reflects on identified areas of strength that offer opportunity for improvement. Ensures that written documentation and oral communication focuses on pertinent information to support meeting patient/family care needs. Serves as the patient's advocate and coordinator of care, working collaboratively with providers and other members of the healthcare team. Performs other duties as assigned. Supervisory/Management Responsibility This is a non-management job that will report to a supervisor, manager, director or executive. Minimum Requirements Education - Associate degree in Nursing. Bachelor's degree in Nursing preferred. Experience - One (1) year experience as a registered nurse. In Lieu Of In lieu of one (1) year of registered nurse experience, will accept successful completion of the Prisma Health Nurse Residency Program or successful completion of a comparable residency from another organization. In lieu of one (1) year of registered nurse experience, will accept 1 year of licensed practical nurse (LPN) experience for internal candidates within the same service line. In lieu of Associate degree in nursing, will accept nursing diploma with licensure to practice as a registered nurse. Required Certifications, Registrations, Licenses Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working. Knowledge, Skills and Abilities NA Work Shift Day (United States of America) Location Baptist Easley Med Campus Facility 1015 Baptist Easley Hospital Department 10156354 Medical/Surgical Nursing Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.