JOB DETAILS
- 3-4 Days of Home Visits (within an hour drive in the assigned territory) and 1-2 Days of Telehealth
- 4 Patients a Day for Home Visits
- 6 Patienta a Day for Telehealth
- Monday
- Friday, 8AM-5PM (Exceptions when patients request a visit after 5PM)
- Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care.
- This position will work with underserved populations.
- Competitive compensation package including negotiable salary and bonus.
- Flexible paid leave and vacation policy.
- Laptop, mileage reimbursement, phone allowance, and extra perks available!
- 1-Week Training in company headquarters in Nashville (All-Expense Paid) JOB SUMMARY This is a care management position, in which Care Manager
- RNs will create and administer care plans, rather than rendering direct clinical services. Care Managers
- RNs lead the effort to help prevent costly and traumatic episodes such as avoidable hospitalizations, readmissions, and unexpected kidney failure. For those already on dialysis, Care Managers
- RNs provide additional support, particularly around transitions in care such as hospital discharges. RESPONSIBILITIES
- Develop and continually adapt an individualized care plan in conjunction with Monogram physicians
- Perform frequent daily in-home care management visits to execute care management plans
- Serve as the primary point of contact and be the first call when members have questions about their health
- Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds
- Understand the needs of Monogram health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly
- Use personal communication skills, patience and diligence to engage plan members and their caregivers
- Perform post-op and hospital discharge visits to help plan members through vulnerable transitions
- Review and document plan member updates and progress in care management platform
- Monitor biometric data and follow approved protocols for any necessary interventions
- Inventory and reconcile medications and coordinate with pharmacists and prescribers
- Perform plan member 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 members
- Engage positively with Monogram social workers to facilitate social and behavioral needs to of plan members
- Educate members and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
- Coordinate with dialysis providers to ensure transitions of care are seamless REQUIREMENTS
- California RN license
- Graduate of an accredited school of nursing
- 1+ years previous experience working in care management and/or with Chronic Kidney Disease (CKD)/End Stage Renal Disease (ESRD) patients is preferred.
- Home Health and/or Hospice experience preferred
- Ability to take call remotely on some nights and weekends
- Ability to drive to patients’ homes