RN Care Manager

Overview

Required skills & experience: 1) Graduate of an accredited School of Nursing. 2) Currently licensed as a Registered Nurse in the State of Texas (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. 3) Flexible paid leave and vacation policy. 4) This position is in-and-around Austin, TX with significant daily automobile travel throughout the territory. 5) This position will work with underserved populations, mostly Spanish speaking. 6) Laptop, mileage reimbursement, phone allowance, and extra perks available! Additional Job Details: 1) We are a care management company that, through teams of experienced physicians, nurses and social workers, works with health plans to raise the quality and lower the cost or care for health plan members with kidney disease and associated co-morbidities. 2) RNs have the opportunity to improve the lives of health plan members with kidney disease. Care Manager – RNs build long-term meaningful relationships by visiting members of their panel every day at home, face-to-face, during regularly scheduled visits. From those visits, they gather important information that can be communicated to the plan members’ nephrologists, primary care physicians and other healthcare providers. 3) 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. 4) Care Managers – RNs work with plan members to educate them about treatment options, including different modalities of dialysis and palliative care. They encourage healthy behaviors and ensure plan members are well-informed to make proactive decisions about their health. 5) Care Managers – RNs have the commitment, fortitude and personal skills to visit and engage with plan members who may be hard to reach, have behavioral health issues or are otherwise going through significant physical and emotional challenges. 6) Resources available include a clinical management team that includes nephrologists and nurses, social worker colleagues who focus on social determinants of health, custom care management software platform, wireless biometrics, patient-friendly education materials, and a pharmacist performing regular comprehensive medication reviews. 7) Develop and continually adapt an individualized care plan in conjunction with Monogram physicians 8) Perform frequent daily in-home care management visits to execute care management plans 9) Serve as the primary point of contact and be the first call when members have questions about their health 10) Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds 11) Understand the needs of Monogram health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly 12) Use personal communication skills, patience and diligence to engage plan members and their caregivers 13) Perform post-op and hospital discharge visits to help plan members through vulnerable transitions 14) Review and document plan member updates and progress in care management platform 15) Monitor biometric data and follow approved protocols for any necessary interventions 16) Inventory and reconcile medications and coordinate with pharmacists and prescribers 17) Perform plan member health assessments and surveys as required 18) Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities 19) Encourage medication and treatment adherence through frequent contact with members 20) Engage positively with Monogram social workers to facilitate social and behavioral needs to of plan members

Qualifications

• Valid Registered Nurse (RN) in Texas (TX)
• Home Health Care (2+ years)
• 2+ years of experience in ANY of the following:
  • Geriatric Care
  • Dialysis Care
  • Hospice
• Are you fully vaccinated?
• Are you seeking a full-time opportunity?
• Are you comfortable traveling to patient's homes at this time?

• Which of Monogram's core values do you identify with the most?

Benefits

Company

Our client is a Hospital and Healthcare Company that is a provides in-home nephrology, primary care, and benefit management services for individual with chronic kidney and end-stage renal disease.