Care Manager - Rn

Required skills & experience:

1. Graduate of an accredited School of Nursing.
2. Currently licensed as a Registered Nurse in the State in which you are applying (or another NLC state).
3. 2+ years of previous experience working in care management and/or with CKD/ESRD patients is preferred.
4. Ability to take calls 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 including salary and bonus.
3. Flexible paid leave and vacation policy.
4. This position is in-and-around metro Boston, MA.
5. This position will work with underserved populations.
6. Laptop, mileage reimbursement, phone allowance, and extra perks available!

Additional Job Details:

• 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, and 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 the 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 the social and behavioral needs 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
• This is a care management position in which Care Managers RNs will create and administer care plans rather than render 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.