Care Manager - Registered Nurse - South Savannah, GA

Care Manager - Registered Nurse - South Savannah, GA

Monogram Health is looking for a skilled Registered Nurse to join their Care Team and make a difference in patients’ lives.

As a Care Manager RN, you will be a key member of an integrated Care Team—including an Advanced Practice Provider and a Social Worker—to help patients improve their quality of life in the home and slow the progression of kidney disease.

You will build trusting relationships with patients, work with a small panel to directly impact their care, and put patients’ quality of life at the forefront.

• Flexible scheduling with a hybrid and in-home model
• Competitive compensation and a performance-based bonus program
• Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time

• Work closely with patients’ medical providers to develop and continually adapt care plans
• Perform in-home care management visits to execute the care management plan
• Monitor biometric data and follow approved protocols for interventions
• Inventory and reconcile medications and coordinate with pharmacists and prescribers
• Perform patient health assessments and surveys as required
• Deliver individual and group education on CKD, ESRD, dialysis, and comorbidities
• Encourage medication and treatment adherence through frequent contact with patients
• Engage family and social support groups in education and care of patients
• Serve as the primary point of contact and first call when patients have questions during business hours
• Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices
• Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
• Obtain vital signs during visits and elevate concerns to the provider
• Initiate patient relationships through enrolment and onboarding processes
• Perform post-op and hospital discharge visits to help patients through vulnerable transitions
• Review and document patient updates and progress in the care management platform
• Coordinate with dialysis providers to ensure seamless transitions of care

• Frequent local travel to perform in-home visits
• Basic Life Support (BLS) certification required; the company will support completion during onboarding
• Infrequent domestic travel may be required, mainly to Brentwood, TN for training
• Self-starter capable of working independently with minimal supervision
• Empathetic and able to build relationships with patients and physicians quickly
• Graduate of an accredited School of Nursing
• Currently licensed as a Registered Nurse in the State of posting location
• At least 2 years of experience in care management and/or with CKD/ESRD patients
• Ability to take calls remotely on some nights and weekends
• Excellent verbal communication skills in person and on the phone
• Familiarity with Microsoft Office and mobile and web-based applications

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for complex patients with multiple chronic conditions. Their comprehensive and personalized approach treats all chronic conditions present—such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. The team includes specialists across nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose, prescribe, and educate.

Monogram Health offers 24/7 support to patients in their homes and its innovative model dramatically improves outcomes while reducing costs.