Nurse Practitioner

Job Description

Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager to make a difference in patients' lives. The Advanced Practitioner is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. Patients often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex patients with multiple chronic conditions.

Deliver personalized compassionate medical care to individuals primarily with CKD and/or ESRD/ESKD. Responsible for caring for patients, maintaining accurate and current patient records, scheduling, and administering follow-up appointments as required. Your skills are urgently needed to put patients and their quality of life at the forefront of care.

• Flexible scheduling with a hybrid and in-home model
• Value-based care, patient-focused and allows you to spend time with those in your care
• Competitive compensation consistent with MGMA guidelines
• Comprehensive medical, dental, vision and life insurance
• Paid vacation and holiday time
• 401(k) plan with matching contributions
• Paid relocation assistance – location and case dependent

• Conduct assessments, including comprehensive annual wellness exams at patients' homes and virtually
• Counsel and educate patients and families about benefits and programs to live healthier lives
• Document items such as chief complaint, all applicable diagnosis, past medical, family, social history, review of systems, examinations, medications, allergies, assessment, and plan
• Coordinate care with primary care providers, specialists, and appropriate ancillary services
• Complete all documentation and paperwork in a timely manner
• Maintain quality of care standards as defined by the practice
• Remote in state; periodic training/meetings outside of that state
• Deliver evidence-based, timely care to reduce avoidable hospitalizations, maximize quality of life, and prioritize patient health and satisfaction
• Prescribe medications, order tests, and collaborate with patient’s Monogram physician
• Perform daily performance, reflected by improved patient quality outcomes
• Facilitate closing gaps in care by educating patients about preventive monitoring and scheduling diagnostic testing
• Assist patients with enrolling to access educational videos
• Participate in the integrated care team meetings
• Knowledge of disease diagnosis and prevention
• Assess patient health status, develop treatment plan, and implement plan consistent with appropriate plan of care
• Follow-up and evaluate patient status
• Other duties as assigned

• Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license
• Board certified (NP: ANCC/AANP; PA: NCCPA)
• Current and unrestricted DEA certificate
• Ability to work without direct supervision and practice autonomously
• Valid driver’s license, car insurance, and access to transportation
• Proficient with medical instruments and equipment required by the work
• Knowledge of computer-based data management programs and information systems, and medical records and point-of-interview technology
• Effective verbal and written communication with patients, families, physicians, and community partners
• Sound understanding of federal and state regulations including HIPAA and OSHA
• 2 or more years of direct patient care required
• Managed Care/IPA/Health Plan experience
• Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with multiple chronic conditions. The team leverages specialists across nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; and provide guidance, education, and counseling on a patient’s healthcare options. Monogram Health is available 24/7 and on holidays to support and treat patients in their home.