Registered Nurse (RN) - Care Manager
Monogram Health
New Holland, PA

Care Manager - Registered Nurse

Position: Care Manager - Registered Nurse 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. At Monogram Health, our mission is to transform the way health care is delivered for those with kidney disease so they can lead healthier, happier, and more fulfilling lives. This transformation is urgently needed. In our healthcare system, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. The Care Manager - RN is a key member of an integrated Care Team which includes a 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. Roles and Responsibilities * 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 escalate 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 * Review and document patient updates and progress in care management platform * Coordinate with dialysis providers to ensure transitions of care are seamless Position Requirements * Infrequent domestic travel may be required, primarily to Brentwood, TN * 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 * 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 * Flexible paid leave and vacation policy * 401(k) plan with matching contributions * About Monogram Health Monogram Health is a value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to transform the way nephrology, primary care and chronic condition treatment is delivered. Monogram's in-home approach utilizes a national nephrology practice supported by case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs. By increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.