JOB DETAILS

• Multiple Openings in Several Locations:
  • Boston
  • Barnstable
  • Cambridge
  • Essex
  • Framingham
  • Newton
  • Pittsfield
  • Springfield
  • Worcester
• Home Visits and Telehealth
• Monday – Friday, 8AM-5PM (Exceptions when patients request a visit after 5PM)
• Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care. 
• This position will work with underserved populations.
• Competitive compensation package including salary and bonus.
• Flexible paid leave and vacation policy.
• Laptop, mileage reimbursement, phone allowance, and extra perks available!

JOB SUMMARY

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.

RESPONSIBILITIES

• Develop and continually adapt an individualized care plan in conjunction with Monogram physicians
• Perform frequent daily in-home care management visits to execute care management plans
• Serve as the primary point of contact and be the first call when members have questions about their health
• Prepare care recommendations and escalations for plan members, write reports regarding the same and communicate the same in weekly internal case rounds 
• Understand the needs of Monogram health plan managed care clients and prioritize plan member visits, recommendations and focus accordingly
• Use personal communication skills, patience and diligence to engage plan members and their caregivers
• Perform post-op and hospital discharge visits to help plan members through vulnerable transitions
• Review and document plan member updates and progress in care management platform
• Monitor biometric data and follow approved protocols for any necessary interventions 
• Inventory and reconcile medications and coordinate with pharmacists and prescribers
• Perform plan member health assessments and surveys as required
• Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities
• Encourage medication and treatment adherence through frequent contact with members
• Engage positively with Monogram social workers to facilitate social and behavioral needs to of plan members
• Educate members and facilitate conversations around proactive care decisions, especially relating to transplantation, home modalities and proactive AV fistula placement
• Coordinate with dialysis providers to ensure transitions of care are seamless

REQUIREMENTS 

• Active and unrestricted Massachusetts RN license
• Graduate of an accredited school of nursing
• 2+ years previous experience working in care management and/or with Chronic Kidney Disease (CKD)/End Stage Renal Disease (ESRD) patients is preferred.
• Must have Home Health and/or Hospice experience.
• Ability to take calls remotely on some nights and weekends
• Ability to drive to patients’ homes