Care Manager – Registered Nurse

Monogram Health
September 20, 2022
Philadelphia, PA
Job Type


Position: Care Manager - RN

Monogram Health Care Managers have the opportunity to improve patient lives each and every day. Care Managers build long-term meaningful relationships by working with the same panel of patients face-to-face in the patients home. In close partnership with local nephrologists and with the support of a care team, including a social worker and a care coordinator, Care Manager - RNs lead the effort to help our patients have higher quality care, slower progression of kidney disease, and a reduction in traumatic and costly episodes such as avoidable hospitalizations, readmissions, unexpected kidney failure and unplanned or clinically inappropriate dialysis starts.

Care Managers work with patients to encourage healthy behaviors and ensure patients are well informed and empowered to make proactive decisions about their own care. Tools available include a custom care management software platform, wireless biometrics patient-friendly education materials, and pharmacists performing regular comprehensive medication reviews.

A successful Care Manager RN builds friendly, trusting relationships with Monogram program members. While the company is kidney-focused, the Care Manager monitors all of the members health conditions, which typically include hypertension, diabetes and cardiopulmonary issues. Care Manager RNs have a value-based, outcomes-oriented mentality and desire to be part of a company that simultaneously raises health outcomes while lowering costs through preventing unnecessary or avoidable clinical episodes.

The Care Manager proactively communicates with the patients to ensure that if the program members health is deteriorating, the Care Manager will make appropriate interventions to get the member seen by the appropriate physician, ensure appropriate medications are prescribed and that preventive, outpatient medicine is delivered wherever possible.

Care Managers care deeply about their patients as people. They have strong interpersonal skills and experience dealing with patients who and truly believe that the work they do makes a difference.

Position Requirements

  • This position covers Philadelphia and surrounding counties
  • Self-starter with the ability to work independently with minimal supervision
  • Ability to show empathy and quickly build relationships with patients and physicians
  • Graduate of an accredited School of Nursing
  • Currently licensed as a Registered Nurse in Pennsylvania
  • 3+ years previous experience working in managed care, care management, home health and/or with CKD/ESRD patients
  • Excellent verbal communication skills both in person and on the phone
  • Sharp clinical documentation skills
  • Ability to learn new mobile phone and web-based applications

Roles and Responsibilities

  • Perform in-home visits and assessments daily with members who have kidney disease and multiple co-morbidities, with the aim of engaging the patient in a proactive plan of care that slows the progression of kidney disease and facilitates preventive care and avoidance of unnecessary hospitalizations
  • Interact daily with members who suffer from challenging physical health, emotional health and socioeconomic conditions, with compassion and patience
  • Develop individualized care management plans
  • Continually monitor and document progress and new developments with respect to care plan goals
  • Serve as the primary point of contact and be the first call when patients have questions
  • Develop strong grasp of evidence-based criteria for kidney treatment pathways
  • Work closely with corporate physicians and nurses to identify patients at high risk of kidney failure and focus on making sure those patients have an appropriate care plan and avoid uninformed, unplanned dialysis starts
  • Monitor biometric data and follow approved protocols for any necessary interventions
  • Inventory and reconcile medications and coordinate with pharmacists and prescribers; encourage medication treatment adherence through interactions with patients and their physicians and nurses
  • Conduct member education on CKD, ESRD, dialysis and associated comorbidities, as well as dietary and lifestyle choices
  • Serve as the primary point of contact and be the first call when patients have questions
  • Develop strong grasp of evidence-based criteria for kidney treatment pathways
  • Educate patients and facilitate conversations around proactive care decisions, especially relating to transplantation, home dialysis modalities proactive AV fistula placement and conservative care where necessary
  • Make patients lives easier by scheduling office appointments, working with company social workers to arrange for transportation and financial assistance where needed
  • Perform post-op and hospital discharge visits to help patients through vulnerable transitions
  • Review and document patient updates and progress in electronic care management platform
  • Coordinate with dialysis providers to ensure transitions to dialysis are seamless and that patients receive prompt and thorough training prior to dialysis starts
  • Support Monogram Health as necessary with any tasks required to deliver excellent personalized kidney care and perform all other duties as assigned
  • Uphold the mission and values of Monogram Health in all aspects of your role and activities


  • Opportunity to work in a dynamic, fast-paced and innovative care management company that is transforming the delivery of kidney care
  • Highly competitive salary
  • Comprehensive medical, dental, vision and life insurance
  • Flexible paid leave & vacation policy
  • 401(k) plan with matching contributions

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.

Job Type: Full-Time

Work Remotely: No

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