- 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
- 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 Florida
- 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
- Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care
- Competitive salary and opportunity to participate in the company's bonus program
- Comprehensive medical, dental, vision and life insurance
- Flexible paid leave and vacation policy
- 401(k) plan with matching contributions
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Care Manager - Jacksonville Beach, United States - Monogram Health
Description
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
Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders.
Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum.
By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.
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.
