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Care Manager RN - Flowery Branch, GA

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.

Travel Advanced Practice Provider - North New Jersey

Monogram Health NJ

Position: Travel - Advanced Practice Provider - North New Jersey The Monogram Advanced Practice Provider is a Nurse Practitioner is a critical role that provides access to comprehensive care to underserved patients within their assigned territory. The Advanced Practice Provider will be responsible for delivery of personalized compassionate medical care to patients primarily with CKD through ESRD. The Advanced Practice Provider will be responsible for caring for patients, maintaining accurate patient records and scheduling and administering follow-up appointments to patients as required across multiple markets. The successful candidate will work as a team with our field-based nurses, community health workers, and physicians to assist in delivering premium care to every patient. Primary duties include patient health assessment, creating strategies to improve or manage a patient's health, and introducing habits for health promotion. Advanced Practice Providers perform the important task of educating patients about preventative care and prescribed treatments. He/she may also conduct physicals, order tests, prescribe medications, and serve as a coordinator with the patient's primary healthcare provider and their specialists. Roles and Responsibilities Travels throughout assigned territory to conduct home conducts in-home assessments, which include comprehensive annual wellness exams, focused screenings, or other visits both in the patients' home and in the virtual environment Ability to travel out of state for up to 2-weeks at a time as necessary 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 Active and unrestricted Registered Nurse and Nurse Practitioner Board certified for appropriate licensure (NP: ANCC/AANP) Current and unrestricted DEA certificate Ability to travel up to 75% of the time 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 Bilingual in Spanish is a plus; but not required Managed Care/IPA/Health Plan experience Experience conducting wellness visits, focused assessments, or similar comprehensive visits virtually or in the home 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.

Travel Nurse Practitioner

Monogram Health Houston, TX

Position: Travel Nurse Practitioner Monogram Health is looking for a skilled Nurse Practitioner eager for the opportunity to make a difference in patients’ lives. The Monogram Travel Nurse Practitioner plays a critical role in providing access to comprehensive care for underserved patients our Monogram Health network reach. Also, helping patients improve their quality of life in the home and slow the progression of kidney disease and multiple other chronic illnesses, enabling positive health outcomes. Your Impact: As a Travel Nurse Practitioner, you will be responsible for the delivery of personalized and compassionate care to patients primarily with CKD through ESRD. Monogram’s Travel NPs will become nationwide float providers to the members in areas where our local clinicians are unable to reach and in areas where we are rapidly growing. Primary duties include patient health assessment, creating strategies to improve or manage a patient's health, and introducing habits for health promotion. In part of completing this care for patients, your responsibilities will include maintaining accurate patient records, scheduling, and administering follow-up appointments to patients as required across multiple markets. Highlights & Benefits Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care Competitive salary Comprehensive medical, dental, vision and life insurance (1099 options also available) Flexible paid leave and vacation policy 401(k) plan with matching contributions Roles and Responsibilities Travels statewide or nationwide to conduct in-home assessments, which include comprehensive annual wellness exams, focused screenings, or other visits both in the patients' home and in the virtual environment Ability to travel out of town for up to 75% of the month during the work week 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 based 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 Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Active and unrestricted Registered Nurse and Nurse Practitioner Board certified for appropriate licensure (NP: ANCC/AANP) Current and unrestricted DEA certificate, or eligibility Ability to travel extensively by air and utilize rental vehicles 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 Nurse Practitioner experience 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. #TNP #LI-JE1 #LI-Hybrid