Rn Care Manager


  • 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

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