Care Manager - Registered Nurse

Position: Care Manager – 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.    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 Arizona (or other NLC state)  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 compe