Care Manager - Registered Nurse; RN

Monogram Health Care Managers have the opportunity to improve patient lives each and every day. Care Managers build long-term meaningful relationships by working with the same small panel of patients face-to-face in the patients’ homes. In close partnership with local nephrologists and with the support of a Care Team including a Social Worker and a Care Coordinator, Care Managers lead the effort to help our patients achieve better quality outcomes and slower progression of kidney disease while reducing costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure.

For those already on dialysis, our Care Managers will provide additional support particularly around transitions in care, such as hospital discharges.

Care Managers work with patients to encourage healthy behaviors and ensure patients are well informed and empowered to make proactive decisions about their own care. Tools available include a custom care management software platform, wireless biometrics, telehealth capabilities, patient-friendly education materials, and pharmacists performing regular comprehensive medication reviews. Care Managers care deeply about their patients as people and truly believe that the work they do makes a difference.

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 k 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.

The base salary range for this role is full range, $80,072 to $96,836 and reflects the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While a larger range is posted, most offers will typically fall within a narrower band based on these factors.

In addition to base salary, this role is eligible for additional compensation, including bonus opportunities and a comprehensive benefits package.

• Work closely with patients’ nephrologists 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
• Provide education and coaching around diet, exercise, and lifestyle choices
• Educate patients and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
• Obtain vital signs when visiting patient and escal ate any concerns to the nephrologist
• Facilitate nephrologist contact with other physicians to ensure comorbidities are managed
• Initiate patient relationships through enrolment and onboarding processes
• Perform post-op and hospital discharge visits to help patients through vulnerable transitions
• Revie…