Position: Care Manager – SW

Monogram Health Care Managers are in the perfect position to facilitate meaningful improvement in the lives of very ill patients. A significant number of patients with Chronic Kidney Disease and End Stage Renal Disease are economically disadvantaged and lacking the support needed to care for themselves properly, all while often struggling with multiple serious diseases and behavioral health challenges. Care Managers can remove the many economic and behavioral barriers to patients experiencing great health outcomes.

As a key member of a Care Team which includes a Nurse Care Manager and a Care Coordinator, the Care Manager - SW works with patients face-to-face, over the phone and through telehealth to identify and address social determinants of health, build up and engage a patient’s social support network, navigate behavioral challenges, and generally help patients through a very traumatic diagnosis and life-changing disease. Monogram Health Care Managers believe that improving social determinants of health will improve health outcomes, and they will work hard to develop strong relationships with their patients and ensure that every resource available is made available and utilized to improve the health and well-being of their patients.

Roles and Responsibilities

• Perform in-home care management visits to assess and impact social and behavioral status
• Work closely with Care Team to ensure continual progress on all care management goals
• Assess social determinants of health needs and develop a plan for addressing them
• Perform behavioral, environmental, and social support assessments and surveys as needed
• Deliver individual, family and group education on living with chronic illness
• Engage family and social support groups in the education and care of patients
• Assess patients and refer to behavioral health specialists if diagnosis and treatment needed
• Help patients to understand, accept and follow medical and lifestyle recommendations
• Serve as the point of contact for patient questions regarding social and behavioral
• Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement
• Initiate patient relationships through enrolment and onboarding processes
• Review and document patient updates and progress in care management platform
• Identify, vet, and build relationships with local Community-Based Organizations
• Introduce patients to appropriate resources and act as the patient advocate
• Serve as subject matter expert on social determinants for other members of the Care Team

Position Requirements

• This position involves car travel to patients’ homes
• Currently licensed as a LCSW or LMSW in the posted state
• Rare domestic travel may be required 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 local CBOs
• Master’s Degree in Social Work, behavioral sciences, or another related field
• 2 years previous experience working in care management and/or with chronic illness
• Ability to occasionally visit patients or 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

• Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care
• Competitive salary
• Comprehensive medical, dental, vision and life insurance
• Flexible paid leave and vacation policy
• 401(k) plan with matching contributions

About Monogram Health

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 seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. 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. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.