We are looking for RN's that have 2 years of experience in the following. This will be a full-time position. You will be traveling to patients' homes. 

• Dialysis Care

• Home Health Care 

• Hospice 

• Case Management (CM)

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.

Benefits

• Full Benefits (Medical, Dental, & Vision)

• 401K Plan • PTO, Sick Days

• Competitive Compensation •

Laptop, Phone Allowance (if applicable details will be listed on job)

• Internal Growth Opportunities