Care Manager - Registered Nurse

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Monogram Health is looking for a skilled Registered Nurse eager to make a difference in patients’ lives. The Care Manager RN is a key member of an integrated Care Team that includes an Advanced Practice Provider and a Social Worker. Patients often struggle with multiple serious diseases; the RN helps improve quality of life at home, slows kidney disease progression, and achieves positive outcomes.

As a Registered Nurse, you build trusting relationships with patients to help them experience a high quality of life  work with a small panel of patients, directly impacting care. At Monogram, we put patients and their quality of life at the forefront.

• Flexible scheduling with a hybrid and in‑home model
• 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

• Work closely with patients’ medical providers to develop and continually adapt care plans
• Perform in‑home care management visits to execute care management plans
• 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 elevate any concerns to the provider
• Initiate patient relationships through enrollment 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

• Frequent local travel to perform in‑home visits
• Basic Life Support (BLS) certification is required. The company will support 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
• Empathy and ability to build relationships quickly with patients and physicians
• Graduate of an accredited School of Nursing
• 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

Monogram Health is a leading multispecialty provider of in‑home, evidence‑based care for the most complex patients with multiple chronic conditions. We take a comprehensive and personalized approach, treating not only a disease but all chronic conditions present—such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Our robust clinical team includes specialists across multiple disciplines: nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care.

We support patients 24/7, including holidays, to deliver care in their home.