Care Manager RN

Company: Monogram Health
Location: Pearland
Posted on: August 6, 2022

Job Description:

Position: Care Manager - RN Monogram Health Care Managers have the opportunity to improve patient lives each and every day. Care Managers build long-term meaningful relationships by working with the same panel of patients face-to-face in the patient's home. In close partnership with local nephrologists and with the support of a care team, including a social worker and a care coordinator, Care Manager - RNs lead the effort to help our patients have higher quality care, slower progression of kidney disease, and a reduction in traumatic and costly episodes such as avoidable hospitalizations, readmissions, unexpected kidney failure and unplanned or clinically inappropriate dialysis starts. Care Managers work with patients to encourage healthy behaviors and ensure patients are well informed and empowered to make proactive decisions about their own care. Tools available include a custom care management software platform, wireless biometrics patient-friendly education materials, and pharmacists performing regular comprehensive medication reviews. A successful Care Manager RN builds friendly, trusting relationships with Monogram program members. While the company is kidney-focused, the Care Manager monitors all of the member's health conditions, which typically include hypertension, diabetes and cardiopulmonary issues. Care Manager RNs have a value-based, outcomes-oriented mentality and desire to be part of a company that simultaneously raises health outcomes while lowering costs through preventing unnecessary or avoidable clinical episodes. The Care Manager proactively communicates with the patient's to ensure that if the program member's health is deteriorating, the Care Manager will make appropriate interventions to get the member seen by the appropriate physician, ensure appropriate medications are prescribed and that preventive, outpatient medicine is delivered wherever possible. Care Managers care deeply about their patients as people. They have strong interpersonal skills and experience dealing with patients who and truly believe that the work they do makes a difference. Position Requirements This position covers Rockingham County and surrounding counties
Self-starter with the ability to work independently with minimal supervision
Ability to show empathy and quickly build relationships with patients and physicians
Graduate of an accredited School of Nursing
Currently licensed as a Registered Nurse in New Hampshire
3+ years previous experience working in managed care, care management, home health and/or with CKD/ESRD patients
Excellent verbal communication skills both in person and on the phone
Sharp clinical documentation skills
Ability to learn new mobile phone and web-based applications Roles and Responsibilities Perform in-home visits and assessments daily with members who have kidney disease and multiple co-morbidities, with the aim of engaging the patient in a proactive plan of care that slows the progression of kidney disease and facilitates preventive care and avoidance of unnecessary hospitalizations
Interact daily with members who suffer from challenging physical health, emotional health and socioeconomic conditions, with compassion and patience
Develop individualized care management plans
Continually monitor and document progress and new developments with respect to care plan goals
Serve as the primary point of contact and be the first call when patients have questions
Develop strong grasp of evidence-based criteria for kidney treatment pathways
Work closely with corporate physicians and nurses to identify patients at high risk of kidney failure and focus on making sure those patients have an appropriate care plan and avoid uninformed, unplanned dialysis starts
Monitor biometric data and follow approved protocols for any necessary interventions
Inventory and reconcile medications and coordinate with pharmacists and prescribers; encourage medication treatment adherence through interactions with patients and their physicians and nurses
Conduct member education on CKD, ESRD, dialysis and associated comorbidities, as well as dietary and lifestyle choices
Serve as the primary point of contact and be the first call when patients have questions
Develop strong grasp of evidence-based criteria for kidney treatment pathways
Educate patients and facilitate conversations around proactive care decisions, especially relating to transplantation, home dialysis modalities proactive AV fistula placement and conservative care where necessary
Make patients' lives easier by scheduling office appointments, working with company social workers to arrange for transportation and financial assistance where needed
Perform post-op and hospital discharge visits to help patients through vulnerable transitions
Review and document patient updates and progress in electronic care management platform
Coordinate with dialysis providers to ensure transitions to dialysis are seamless and that patients receive prompt and thorough training prior to dialysis starts
Support Monogram Health as necessary with any tasks required to deliver excellent personalized kidney care and perform all other duties as assigned
Uphold the mission and values of Monogram Health in all aspects of your role and activities Benefits Opportunity to work in a dynamic, fast-paced and innovative care management company that is transforming the delivery of kidney care
Highly competitive salary
Comprehensive medical, dental, vision and life insurance
Flexible paid leave & vacation policy
401(k) plan with matching contributions 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. Job Type: Full-Time Work Remotely: No
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Keywords: Monogram Health, Pearland , Care Manager RN, Healthcare , Pearland, Texas