Community & Inpatient Care Manager

Job Description

Position: Community & Inpatient Care Manager

At Monogram Health, we are transforming care for high-risk patients with kidney disease and other polychronic conditions, and as an Community & Inpatient Care Manager, you are at the heart of that mission. In this role, you will engage face-to-face with Monogram-eligible patients who could benefit from our services but are not currently enrolled in our program. By educating patients on Monogram, answering their questions, and building their trust, you’ll help connect them to life-changing care. Your outreach has the power to dramatically improve someone’s health, well-being, and quality of life, making every visit an opportunity to make a meaningful difference.

The Community & Inpatient Care Manager reports directly to a Regional Engagement Manager and is responsible for engaging with Monogram’s patients and their families in inpatient facilities and their homes. To do so, the Community & Inpatient Care Manager will be required to routinely visit patient homes and local hospitals and introduce them to Monogram Health. In all these situations, the Community & Inpatient Care Manager will need to be empathetic, inquisitive, and resourceful to identify and solve the patient’s unique needs.

This role’s primary responsibility is to find, engage and enroll new patients in the Monogram program. However, this person will also spend time visiting currently enrolled patients who are hospitalized and provide support with discharge planning or social services. In many instances, this person will need to coordinate with hospital or payer staff to gain access and reach these objectives. The Community & Inpatient Care Manager must be confident and able to overcome barriers to access facilities and patients. This person will attend their Pod’s daily concurrent review rounds, to stay apprised of newly admitted patients and build their work queue for the day. Roles and Responsibilities

Drives to and finds patients in their homes and inpatient facilities to engage with them and facilitate enrolling them in the Monogram program

Articulates Monogram’s services and value in an accurate and compelling manner, while respecting boundaries of the patient and family

Ability to engage and build rapport with patients, family and caregivers of diverse socio-economic and cultural backgrounds with multiple chronic conditions and vulnerabilities

Attends daily concurrent review rounds with Pod clinical leaders and works with their manager to build a daily work queue

Reviews inpatient and emergency room admission data through Monogram’s care events

Conducts pre-visit research to better understand each patient’s background and potential needs

Assesses patient’s cognitive status to ensure effective communication, and verifies patient identification and contact details for HIPAA compliance

Identifies social services and discharge planning needs and works with the patient, family and hospital staff to access resources

Serves as an informational resource for patients and families/caregivers regarding their care plan and available services (hospice care, palliative care, long-term acute care, home care, etc.)

Evaluates patient’s progress and effectiveness of resources or services, making necessary and appropriate changes based upon patient’s status

Reviews patient consent status and obtains new consent, if required

Practices within the scope of licensure

Position Requirements

Graduate from an accredited Social Worker or Registered Nurse program of study

Current active Social Worker or Registered Nurse (unrestricted) licensure

Minimum of two (2) years’ previous care management experience

Ability to demonstrate empathy, compassion, and quickly build relationships with patients, family/caregivers, and care teams, including physicians

Ability to handle rejection and keep trying, while respecting patient’ and families’ boundaries

Ability to navigate hospital environments, advocate for access and maintain composure when faced with resistance from hospital staff

Experience assessing vulnerable high-risk patients and advocating for their needs to external staff at hospitals or payers

Demonstrated verbal and written communication skills

Previous experience with electronic health record platforms, MS Office Suite, and mobile phone and web-based applications

Reliable personal transportation, valid driver’s license, and auto insurance

Must live in the desired geography and be willing to travel 2-3 hours per day to visit patients

Ability to work independently with minimal supervision as well as part of a team

Demonstrated initiative and self-starter

Infrequent domestic travel may be required, primarily to Brentwood, TNBenefits

Opportunity to work in a dynamic, fast-paced, and innovative care management company that is transforming the delivery of kidney care.

Competitive salary and opportunity to participate in company’s bonus program.

Comprehensive medical, dental, vision and life insurance

Flexible paid leave & vacation policy

401(k) plan with matching contributions

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.

Full-time