overview

Required skills & experience:

1) Graduate of an accredited School of Nursing.

2) Currently licensed as a Registered Nurse in the State of Michigan (or other NLC state).

3) 2 years previous experience working in care management and/or with CKD/ESRD patients is preferred.

4) Ability to take call remotely on some nights and weekends

5) Must have Home Health and/or Hospice experience.

What You Need to Know:

1) Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care.

2) Competitive compensation package including salary and bonus.

3) Flexible paid leave and vacation policy.

4) This position is in-and-around metro Grand Rapids, MI.

5) This position will work with underserved populations.

6) Laptop, mileage reimbursement, phone allowance, and extra perks available!

Additional Job Details:

1) Develop and continually adapt an individualized care plan in conjunction with Monogram physicians

2) Perform frequent daily in-home care management visits to execute care management plans

3) Serve as the primary point of contact and be the first call when members have questions about their health

4) Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds

5) Understand the needs of Monogram health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly

6) Use personal communication skills, patience and diligence to engage plan members and their caregivers

7) Perform post-op and hospital discharge visits to help plan members through vulnerable transitions

8) Review and document plan member updates and progress in care management platform

9) Monitor biometric data and follow approved protocols for any necessary interventions

10) Inventory and reconcile medications and coordinate with pharmacists and prescribers

11) Perform plan member health assessments and surveys as required

12) Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities

13) Encourage medication and treatment adherence through frequent contact with members

14) Engage positively with Monogram social workers to facilitate social and behavioral needs to of plan members

15) Educate members and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement

16) Coordinate with dialysis providers to ensure transitions of care are seamless

17) 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.