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Care Manager - Registered Nurse

Company: Monogram Health
Location: Philadelphia
Posted on: September 24, 2022

Job Description:

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 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. Roles 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 Pennsylvania
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 behaviors 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.
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Keywords: Monogram Health, Philadelphia , Care Manager - Registered Nurse, Executive , Philadelphia, Pennsylvania

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