RN Full-time

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.  

 

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The available plans and programs include: Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services Wellbeing support, including free counseling and referral services Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence Savings and retirement resources , including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. "Nurses play a pivotal role and are the backbone of healthcare delivery. At HCA Healthcare, we are dedicated to ensuring nurses have necessary tools and resources to provide world-class patient care, advocating for the profession and helping to shape the future of nursing." Sammie Mosier, DHA, MA, BSN, NE-BC Senior Vice President and Chief Nursing Executive, HCA Healthcare Medical City Heart & Spine Hospitals are hospitals for specialized advanced cardiovascular and spine care. The facilities are located near Medical City Dallas. They are designed to be efficient and result in faster recoveries. We offer an enhanced patient experience. Patients will benefit from leading edge treatments and technology. We offer clinical trials. You will have access to the entire network of Medical City Healthcare hospitals and specialists. Medical City Heart Hospital has 65+ private patient rooms. The facility provides a wide array of cardiac services. Services include complex vascular and heart surgery and advanced heart failure treatment. We offer minimally invasive vascular surgery and other specialized heart care. The facility has a dedicated cardiac emergency room. Medical City Spine Hospital has 25+ beds. It provides spine care for common spine disorders. Spine care is also provided for rare, hard-to-treat spinal deformities. Those include adult and pediatric scoliosis and spondylolistheses. We offer complex spine surgery and minimally invasive surgical options. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. Â If this opportunity is your next step in your career path, we encourage you to apply for our Registered Nurse Float Pool opening. We review all applications. Qualified candidates will be contacted by a member of our team. We are interviewing apply today! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.