What are the responsibilities and job description for the Care Manager RN position at Monogram Health?
About Monogram Kidney Care Clinic
Monogram Health supports patients suffering from Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) by forming deep rooted relationships and preparing them both emotionally and physically for the challenges of managing kidney disease.
Position: Care Manager – RN – Louisiana
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. They build long-term meaningful relationships by working with the same small panel of patients face-to-face in the patients’ homes.
Rules and Responsibilities
- Initiate patient relationships through enrollment and onboarding processes
- Perform in-home care management visits to execute care management plan
- Obtain vital signs when visiting patient and escalate any concerns to the nephrologist
- Inventory and reconcile medications and coordinate with pharmacists and prescribers
- Work closely with patients’ nephrologists to develop and continually adapt care plan
- Monitor biometric data and follow approved protocols for any necessary interventions
- 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
- Facilitate nephrologist contact with other physicians to ensure comorbidities are managed
- Perform post-op and hospital discharge visits to help patients through vulnerable transitions
- Coordinate with dialysis providers to ensure transitions of care are seamless
- Review and document patient updates and progress in care management platform
Position Requirements
- This position requires daily travel across the state
- Infrequent domestic travel may be required, primarily to Brentwood, TN
- Graduate of an accredited School of Nursing
- Currently licensed as a Registered Nurse in the State of Louisiana.
- 2 years experience working, as a RN, in care management and/or with CKD/ESRD patients
- Ability to take call remotely on nights and weekends
- Familiarity with Microsoft Office and mobile phone and web-based applications
Benefits
- Opportunity to work in a dynamic, fast-paced, and innovative care management company that is transforming the delivery of kidney care
- Comprehensive medical, dental, vision and life insurance
- Flexible paid leave & vacation policy
- 401(k) plan with matching contributions
- Health Savings Account (HSA) and Flexible Spending Account (FSA)
Monogram Health Care Managers have the opportunity to improve patient lives each and every day by working in close partnership with with local nephrologists and with the support of a Care Team including a Social Worker and a Care Coordinator. Care Managers work with patients to encourage healthy behaviours and ensure patients are well informed and empowered to make proactive decisions about their own care. For those already on dialysis, our Care Managers will provide additional support particularly around transitions in care, such as hospital discharges.
Monogram Health is dedicated to improving the well-being, quality of life and health outcomes for our patients by partnering with the nation's leading kidney specialists to provide transformative kidney care. Monogram Health uses next generation artificial intelligence algorithms to predict necessary and timely care to promote the delay of kidney disease progression, seamless transitions to dialysis and/or pre-emptive kidney transplant. We then utilize in-home visits to build meaningful relationships between patients and their care team that drive positive behavior change and optimize our patients’ health outcomes.
At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.