JOB DETAILS

• 3-4 Days of Home Visits (within an hour drive in the assigned territory) and 1-2 Days of Telehealth
  • 4 Patients/ Day for Home Visits
  • 6 Patients/Day for 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.
• Negotiable Salary
• Excellent Benefits
• Flexible paid leave and vacation policy.
• Laptop, mileage reimbursement, phone allowance, and extra perks available!
• 1-Week Training in company headquarters in Nashville (All-Expense Paid)

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 the company 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

• Colorado RN License or Compact License
• Graduate of an accredited school of nursing
• Direct Patient Care Experience
• Ability to take call remotely on some nights and weekends
• Ability to drive to patients’ homes