Monogram Health jobs - 60 jobs

Clinical Performance Lead We are seeking a highly motivated Clinical Performance Lead to support our clinicians and front-line staff in caring for our members affected by renal disease. As a Clinical Performance Lead, you'll play a vital role at Monogram Health. We are looking for a proactive individual that can help us continually improve and enhance our clinical performance. The duties and responsibilities of the Clinical Performance Lead include, but are not limited to: Roles and Responsibilities Clinical Interventions - 30% Review, update, and manage clinical interventions (CI), ad hoc tasking, and messages concerning visits. This may include the following (but not limited to): document CIs, coach and assist RNs on information needed for tasks (develop action plans with RNs concerning moving up visits, outreach to providers, and/or assist with obtaining updated lab work), make calls to members or physicians to complete tasks, review Care Manager documentation for CI, and review Holy Grail for records to complete tasks. Assist APPs with requests, as well as help with SalesForce (coach/ educate on charting in SalesForce or assessments with RN visits, or tasks with CI). Review appropriate sources (Athena or Health Gorilla) for records of our high-risk members/post-discharge members to better inform RNs at visits. Reviews may include missing or updated GFRs/A1c or pulling Nephrology/PCP/Specialty visit notes for CM review with patients at visits. Perform concurrent review hospital calls (such as review hospitalized patients and discharges). Conduct root cause analysis on certain members. Attend leadership meetings, as needed, such as the MPE meeting. Delegate action to the Patient Support Specialist team to request and receive office visit records for review. Patient Care and Treatment - 15% Review and approve care plans. Discuss patient care with field clinicians (regarding questions or concerns) and provide support and guidance. Also, address clinical escalations from field clinicians too. Facilitate case rounds, PPA clinical rounds, and high-utilizer review, as well as document case rounds follow-up tasks. Execute scheduling needs for high risk, high utilizer members. Perform data analysis, such as data mining for records lab. Address concerns and requests from Pod leadership, such as requests to address a charting concern or coaching for a RN/ NP on SalesForce, and requests to call a member or local providers for various reasons. As needed, speak and document member conversations. Delegate action to the PSS team to request and receive prescriptions and labs for review. Quality Assurance and Compliance - 30% Delegate action to the PSS team to request and receive labs results for review. Audit medical charts and review missing team visit notes (incomplete documentation). Also, review report and email documentation requests to CMs. Conduct data analysis from various downloaded reports (such as ACP's due, CP's due, CRA assessment due, ACP's completed, BCBS enrolled, outstanding CP's due, and Visits 'in progress'.) and create data spreadsheets. Daily review of documentation and provide guidance on IEs & PHDV. Review and correct care plans to ensure compliance with SLA. Provide Bullet Train care coordination. Provide support to field team for escalations, clinical issues, patient outreach, and RR follow up calls. Training and Communication - 25% Provide guidance and education on processes, workflows, and documentation to field staff, as well as review current and upcoming MH organizational changes. Attend standard and ad-hoc operational meetings (on a daily, weekly, and/or monthly cadence). Examples of meetings include (but not limited to): weekly Team meetings, daily Pod Leadership meetings, daily CRS meetings, daily PHDV clinician update meetings, daily discharge planning/PHDV scheduling meetings, weekly Pharmacy rounds, weekly NP high-risk rounds, weekly Pod team huddles, weekly Pod Quad meetings, weekly Bullet Train meetings, weekly CC touch base meetings with Scheduling team, monthly Charl. Nephrology case rounds, monthly MH leadership training and meetings, CM/NP huddles and Pod Tear Sheet meetings, 1:1 meetings with staff, APP meeting, CI office hours meeting, CR meeting, HRR meeting, and Client partnership meeting. Prepare slides and content for standard and ad-hoc operational and clinical meetings. Assisting with scheduling needs, Teams chats, emails, and phone calls. Build reports for specific members and their needs. Position Requirements Current, active unrestricted license as a Registered Nurse in assigned states/territories (compact licensing or multi-state licensing may be required). Minimum 2-years of Registered Nurse experience within the last 5 years, or equivalent clinical experience. Demonstrated knowledge and proficiency using technology. Benefits Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming delivery of kidney care. Competitive salary and opportunity to participate in the company's bonus program. Comprehensive medical, dental, vision and life insurance. Flexible paid leave and vacation policy. 401(k) plan with matching contributions. About Monogram Health 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 Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home model * Value-based care, patient-focused and allows you to spend time with those in your care * Competitive compensation consistent with MGMA guidelines * Comprehensive medical, dental, vision and life insurance * Paid vacation and holiday time * 401(k) plan with matching contributions * Paid relocation assistance- location and case dependent 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here. Roles and Responsibilities * Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment * Counsels and educates patients and families about benefits and programs available to help them live healthier lives * Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan * Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services * Completes all documentation and paperwork in a timely manner * Maintains quality of care standards as defined by the practice * This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state * Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first * Prescribe medications, order tests, and collaborate with patient's Monogram physician * Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily * Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing * Assists patients with enrolling to access educational videos * Participates in the integrated care team meetings * Knowledge of disease diagnosis and prevention * Make assessment of patient's health status * Develop treatment plan * Implement a plan consistent with appropriate plan of care * Follow-up and evaluate patient's status * Other duties as assigned Position Requirements * Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license * Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) * Current and unrestricted DEA certificate * Ability to work without direct supervision and practice autonomously * Access to transportation, a valid driver's license, and car insurance * Must be proficient with medical instruments and equipment required by the work * Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology * Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community * Sound understanding of all federal and state regulations including HIPAA and OSHA * 2 or more years of direct patient care required * Managed Care/IPA/Health Plan experience * Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home mode * Value-based care, patient-focused and allows you to spend time with those in your care * Competitive compensation consistent with MGMA guidelines * Comprehensive medical, dental, vision and life insurance * Paid vacation and holiday time * 401(k) plan with matching contributions * Paid relocation assistance- location and case dependent Roles and Responsibilities * Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment * Counsels and educates patients and families about benefits and programs available to help them live healthier lives * Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan * Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services * Completes all documentation and paperwork in a timely manner * Maintains quality of care standards as defined by the practice * This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state * Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first * Prescribe medications, order tests, and collaborate with patient's Monogram physician * Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily * Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing * Assists patients with enrolling to access educational videos * Participates in the integrated care team meetings * Knowledge of disease diagnosis and prevention * Make assessment of patient's health status * Develop treatment plan * Implement a plan consistent with appropriate plan of care * Follow-up and evaluate patient's status * Other duties as assigned Position Requirements * Bilingual (English/Spanish) highly preferred * Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. * Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license * Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) * Current and unrestricted DEA certificate * Ability to work without direct supervision and practice autonomously * Access to transportation, a valid driver's license, and car insurance * Must be proficient with medical instruments and equipment required by the work * Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology * Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community * Sound understanding of all federal and state regulations including HIPAA and OSHA * 2 or more years of direct patient care required * Managed Care/IPA/Health Plan experience * Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home 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.

Job Description: Care Manager - Registered Nurse Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact: As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home model * Competitive compensation and a performance-based bonus program * Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time Responsibilities * Work closely with patients' medical providers to develop and continually adapt care plan * Perform in-home care management visits to execute care management plan * Monitor biometric data and follow approved protocols for any necessary interventions * Inventory and reconcile medications and coordinate with pharmacists and prescribers * Perform patient 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 patients * Engage family and social support groups in the education and care of patients * Serve as the primary point of contact and be the first call when patients have questions (business hours) * Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices * Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities * Obtain vital signs when visiting patient and escalate any concerns to the provider * Initiate patient relationships through enrolment and onboarding processes * Perform post-op and hospital discharge visits to help patients through vulnerable transitions * Review and document patient updates and progress in care management platform * Coordinate with dialysis providers to ensure transitions of care are seamless Position Requirements * Frequent local travel to perform in-home visits * Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding * Infrequent domestic travel may be required, primarily to Brentwood, TN for training * 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 the State of the posted location * 2+ years previous experience working in care management and/or with CKD/ESRD patients * Ability to take call remotely on some nights and weekends * Excellent verbal communication skills both in person and on the phone * Familiarity with Microsoft Office and mobile phone and web-based applications 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.

Market Physician Executive (MPE) Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health's Multi[1]Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk[1]based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population healthoutcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution - 25% * Know, understand, and deliver on Monogram Health's proprietary evidenced based clinical pathways. * Ensure adherence to established clinical guidelines and Monogram Model of Care. * Review and approve APP, RN, SW and PharmD plans of care. * Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. * Review, approve and co-sign APP encounters. * Clinical and Operations Performance and Quality Improvement - 25% * Overall accountability for reducing total cost of care and Medical Loss Ratio. * Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient * utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure * Actively lead daily high risk and concurrent review rounds. * Direct supervision of front line clinical and operations team members. * Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. * Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment - 25% * Provide direct and indirect patient care (including diagnosis and treatment of disease). * Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. * Conduct Peer to Peers with community, facility, and health plan partners. * Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) - 20% * Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including * identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete * quality post hospital discharge visits, and improving the quality of visits. * Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. * Present and guide population health strategies in clinical and operational meetings. * Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous - * Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. * Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements * Must be willing and able to obtain hospital privileges at required facilities. * This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. * Demonstrated experience applying evidence based clinical criteria. * Experience in renal care and geriatrics. * Strong management and communication skills. * Active, unrestricted state medical license required in each state within the market. * Experience with high need Medicare Advantage and managed Medicaid populations. * Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. * Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. * MD (Medical Doctor) or DO degree from an accredited medical school. * BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, * Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits * Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts * Financial & Retirement Support - Competitive compensation, 401k with employer match, and financial wellness resources * Time Off & Leave - Paid holidays, flexible vacation time/PSSL, and paid parental leave * Wellness & Growth - Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts 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.

Clinical Performance Lead We are seeking a highly motivated Clinical Performance Lead to support our clinicians and front-line staff in caring for our members affected by renal disease. As a Clinical Performance Lead, you'll play a vital role at Monogram Health. We are looking for a proactive individual that can help us continually improve and enhance our clinical performance. The duties and responsibilities of the Clinical Performance Lead include, but are not limited to: Roles and Responsibilities Clinical Interventions - 30% * Review, update, and manage clinical interventions (CI), ad hoc tasking, and messages concerning visits. This may include the following (but not limited to): document CIs, coach and assist RNs on information needed for tasks (develop action plans with RNs concerning moving up visits, outreach to providers, and/or assist with obtaining updated lab work), make calls to members or physicians to complete tasks, review Care Manager documentation for CI, and review Holy Grail for records to complete tasks. * Assist APPs with requests, as well as help with SalesForce (coach/ educate on charting in SalesForce or assessments with RN visits, or tasks with CI). * Review appropriate sources (Athena or Health Gorilla) for records of our high-risk members/post-discharge members to better inform RNs at visits. Reviews may include missing or updated GFRs/A1c or pulling Nephrology/PCP/Specialty visit notes for CM review with patients at visits. * Perform concurrent review hospital calls (such as review hospitalized patients and discharges). * Conduct root cause analysis on certain members. * Attend leadership meetings, as needed, such as the MPE meeting. * Delegate action to the Patient Support Specialist team to request and receive office visit records for review. Patient Care and Treatment - 15% * Review and approve care plans. * Discuss patient care with field clinicians (regarding questions or concerns) and provide support and guidance. Also, address clinical escalations from field clinicians too. * Facilitate case rounds, PPA clinical rounds, and high-utilizer review, as well as document case rounds follow-up tasks. * Execute scheduling needs for high risk, high utilizer members. * Perform data analysis, such as data mining for records lab. * Address concerns and requests from Pod leadership, such as requests to address a charting concern or coaching for a RN/ NP on SalesForce, and requests to call a member or local providers for various reasons. * As needed, speak and document member conversations. * Delegate action to the PSS team to request and receive prescriptions and labs for review. Quality Assurance and Compliance - 30% * Delegate action to the PSS team to request and receive labs results for review. * Audit medical charts and review missing team visit notes (incomplete documentation). Also, review report and email documentation requests to CMs. * Conduct data analysis from various downloaded reports (such as ACP's due, CP's due, CRA assessment due, ACP's completed, BCBS enrolled, outstanding CP's due, and Visits 'in progress'.) and create data spreadsheets. * Daily review of documentation and provide guidance on IEs & PHDV. * Review and correct care plans to ensure compliance with SLA. * Provide Bullet Train care coordination. * Provide support to field team for escalations, clinical issues, patient outreach, and RR follow up calls. Training and Communication - 25% * Provide guidance and education on processes, workflows, and documentation to field staff, as well as review current and upcoming MH organizational changes. * Attend standard and ad-hoc operational meetings (on a daily, weekly, and/or monthly cadence). Examples of meetings include (but not limited to): weekly Team meetings, daily Pod Leadership meetings, daily CRS meetings, daily PHDV clinician update meetings, daily discharge planning/PHDV scheduling meetings, weekly Pharmacy rounds, weekly NP high-risk rounds, weekly Pod team huddles, weekly Pod Quad meetings, weekly Bullet Train meetings, weekly CC touch base meetings with Scheduling team, monthly Charl. Nephrology case rounds, monthly MH leadership training and meetings, CM/NP huddles and Pod Tear Sheet meetings, 1:1 meetings with staff, APP meeting, CI office hours meeting, CR meeting, HRR meeting, and Client partnership meeting. * Prepare slides and content for standard and ad-hoc operational and clinical meetings. * Assisting with scheduling needs, Teams chats, emails, and phone calls. * Build reports for specific members and their needs. Position Requirements * Current, active unrestricted license as a Registered Nurse in assigned states/territories (compact licensing or multi-state licensing may be required). * Minimum 2-years of Registered Nurse experience within the last 5 years, or equivalent clinical experience. * Demonstrated knowledge and proficiency using technology. Benefits * Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming delivery of kidney care. * Competitive salary and opportunity to participate in the company's bonus program. * Comprehensive medical, dental, vision and life insurance. * Flexible paid leave and vacation policy. * 401(k) plan with matching contributions. About Monogram Health Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease. 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 Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Flexible scheduling with a hybrid and in-home model Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here. Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first Prescribe medications, order tests, and collaborate with patient's Monogram physician Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Develop treatment plan Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) Current and unrestricted DEA certificate Ability to work without direct supervision and practice autonomously Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required Managed Care/IPA/Health Plan experience Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home mode * Value-based care, patient-focused and allows you to spend time with those in your care * Competitive compensation consistent with MGMA guidelines * Comprehensive medical, dental, vision and life insurance * Paid vacation and holiday time * 401(k) plan with matching contributions * Paid relocation assistance- location and case dependent Roles and Responsibilities * Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment * Counsels and educates patients and families about benefits and programs available to help them live healthier lives * Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan * Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services * Completes all documentation and paperwork in a timely manner * Maintains quality of care standards as defined by the practice * This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state * Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first * Prescribe medications, order tests, and collaborate with patient's Monogram physician * Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily * Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing * Assists patients with enrolling to access educational videos * Participates in the integrated care team meetings * Knowledge of disease diagnosis and prevention * Make assessment of patient's health status * Develop treatment plan * Implement a plan consistent with appropriate plan of care * Follow-up and evaluate patient's status * Other duties as assigned Position Requirements * Bilingual (English/Spanish) highly preferred * Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. * Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license * Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) * Current and unrestricted DEA certificate * Ability to work without direct supervision and practice autonomously * Access to transportation, a valid driver's license, and car insurance * Must be proficient with medical instruments and equipment required by the work * Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology * Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community * Sound understanding of all federal and state regulations including HIPAA and OSHA * 2 or more years of direct patient care required * Managed Care/IPA/Health Plan experience * Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home 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.

Job Description: Care Manager - Registered Nurse Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact: As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home model * Competitive compensation and a performance-based bonus program * Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time Responsibilities * Work closely with patients' medical providers to develop and continually adapt care plan * Perform in-home care management visits to execute care management plan * Monitor biometric data and follow approved protocols for any necessary interventions * Inventory and reconcile medications and coordinate with pharmacists and prescribers * Perform patient 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 patients * Engage family and social support groups in the education and care of patients * Serve as the primary point of contact and be the first call when patients have questions (business hours) * Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices * Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities * Obtain vital signs when visiting patient and escalate any concerns to the provider * Initiate patient relationships through enrolment and onboarding processes * Perform post-op and hospital discharge visits to help patients through vulnerable transitions * Review and document patient updates and progress in care management platform * Coordinate with dialysis providers to ensure transitions of care are seamless Position Requirements * Frequent local travel to perform in-home visits * Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding * Infrequent domestic travel may be required, primarily to Brentwood, TN for training * 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 the State of the posted location * 2+ years previous experience working in care management and/or with CKD/ESRD patients * Ability to take call remotely on some nights and weekends * Excellent verbal communication skills both in person and on the phone * Familiarity with Microsoft Office and mobile phone and web-based applications 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.

Job DescriptionPosition: Clinical Performance Lead We are seeking a highly motivated Clinical Performance Lead to support our clinicians and front-line staff in caring for our members affected by renal disease. As a Clinical Performance Lead, you'll play a vital role at Monogram Health. We are looking for a proactive individual that can help us continually improve and enhance our clinical performance. The duties and responsibilities of the Clinical Performance Lead include, but are not limited to: Roles and Responsibilities Clinical Interventions - 30% Review, update, and manage clinical interventions (CI), ad hoc tasking, and messages concerning visits. This may include the following (but not limited to): document CIs, coach and assist RNs on information needed for tasks (develop action plans with RNs concerning moving up visits, outreach to providers, and/or assist with obtaining updated lab work), make calls to members or physicians to complete tasks, review Care Manager documentation for CI, and review Holy Grail for records to complete tasks. Assist APPs with requests, as well as help with SalesForce (coach/ educate on charting in SalesForce or assessments with RN visits, or tasks with CI). Review appropriate sources (Athena or Health Gorilla) for records of our high-risk members/post-discharge members to better inform RNs at visits. Reviews may include missing or updated GFRs/A1c or pulling Nephrology/PCP/Specialty visit notes for CM review with patients at visits. Perform concurrent review hospital calls (such as review hospitalized patients and discharges). Conduct root cause analysis on certain members. Attend leadership meetings, as needed, such as the MPE meeting. Delegate action to the Patient Support Specialist team to request and receive office visit records for review. Patient Care and Treatment - 15% Review and approve care plans. Discuss patient care with field clinicians (regarding questions or concerns) and provide support and guidance. Also, address clinical escalations from field clinicians too. Facilitate case rounds, PPA clinical rounds, and high-utilizer review, as well as document case rounds follow-up tasks. Execute scheduling needs for high risk, high utilizer members. Perform data analysis, such as data mining for records lab. Address concerns and requests from Pod leadership, such as requests to address a charting concern or coaching for a RN/ NP on SalesForce, and requests to call a member or local providers for various reasons. As needed, speak and document member conversations. Delegate action to the PSS team to request and receive prescriptions and labs for review. Quality Assurance and Compliance - 30% Delegate action to the PSS team to request and receive labs results for review. Audit medical charts and review missing team visit notes (incomplete documentation). Also, review report and email documentation requests to CMs. Conduct data analysis from various downloaded reports (such as ACP's due, CP's due, CRA assessment due, ACP's completed, BCBS enrolled, outstanding CP's due, and Visits 'in progress'.) and create data spreadsheets. Daily review of documentation and provide guidance on IEs & PHDV. Review and correct care plans to ensure compliance with SLA. Provide Bullet Train care coordination. Provide support to field team for escalations, clinical issues, patient outreach, and RR follow up calls. Training and Communication - 25% Provide guidance and education on processes, workflows, and documentation to field staff, as well as review current and upcoming MH organizational changes. Attend standard and ad-hoc operational meetings (on a daily, weekly, and/or monthly cadence). Examples of meetings include (but not limited to): weekly Team meetings, daily Pod Leadership meetings, daily CRS meetings, daily PHDV clinician update meetings, daily discharge planning/PHDV scheduling meetings, weekly Pharmacy rounds, weekly NP high-risk rounds, weekly Pod team huddles, weekly Pod Quad meetings, weekly Bullet Train meetings, weekly CC touch base meetings with Scheduling team, monthly Charl. Nephrology case rounds, monthly MH leadership training and meetings, CM/NP huddles and Pod Tear Sheet meetings, 1:1 meetings with staff, APP meeting, CI office hours meeting, CR meeting, HRR meeting, and Client partnership meeting. Prepare slides and content for standard and ad-hoc operational and clinical meetings. Assisting with scheduling needs, Teams chats, emails, and phone calls. Build reports for specific members and their needs. Position Requirements Current, active unrestricted license as a Registered Nurse in assigned states/territories (compact licensing or multi-state licensing may be required). Minimum 2-years of Registered Nurse experience within the last 5 years, or equivalent clinical experience. Demonstrated knowledge and proficiency using technology. Benefits Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming delivery of kidney care. Competitive salary and opportunity to participate in the company's bonus program. Comprehensive medical, dental, vision and life insurance. Flexible paid leave and vacation policy. 401(k) plan with matching contributions. About Monogram Health Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease. 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.

Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits   Flexible scheduling with a hybrid and in-home model Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance  Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here. Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment  Counsels and educates patients and families about benefits and programs available to help them live healthier lives  Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan  Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services  Completes all documentation and paperwork in a timely manner  Maintains quality of care standards as defined by the practice  This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state  Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first   Prescribe medications, order tests, and collaborate with patient's Monogram physician  Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily  Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing  Assists patients with enrolling to access educational videos  Participates in the integrated care team meetings  Knowledge of disease diagnosis and prevention  Make assessment of patient's health status  Develop treatment plan  Implement a plan consistent with appropriate plan of care  Follow-up and evaluate patient's status  Other duties as assigned   Position Requirements     Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license  Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA)  Current and unrestricted DEA certificate  Ability to work without direct supervision and practice autonomously  Access to transportation, a valid driver's license, and car insurance  Must be proficient with medical instruments and equipment required by the work  Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology  Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community  Sound understanding of all federal and state regulations including HIPAA and OSHA    2 or more years of direct patient care required  Managed Care/IPA/Health Plan experience  Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home 

Market Physician Executive (MPE) Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health's Multi[1]Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk[1]based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population healthoutcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution - 25% * Know, understand, and deliver on Monogram Health's proprietary evidenced based clinical pathways. * Ensure adherence to established clinical guidelines and Monogram Model of Care. * Review and approve APP, RN, SW and PharmD plans of care. * Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. * Review, approve and co-sign APP encounters. * Clinical and Operations Performance and Quality Improvement - 25% * Overall accountability for reducing total cost of care and Medical Loss Ratio. * Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient * utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure * Actively lead daily high risk and concurrent review rounds. * Direct supervision of front line clinical and operations team members. * Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. * Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment - 25% * Provide direct and indirect patient care (including diagnosis and treatment of disease). * Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. * Conduct Peer to Peers with community, facility, and health plan partners. * Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) - 20% * Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including * identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete * quality post hospital discharge visits, and improving the quality of visits. * Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. * Present and guide population health strategies in clinical and operational meetings. * Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous - * Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. * Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements * Must be willing and able to obtain hospital privileges at required facilities. * This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. * Demonstrated experience applying evidence based clinical criteria. * Experience in renal care and geriatrics. * Strong management and communication skills. * Active, unrestricted state medical license required in each state within the market. * Experience with high need Medicare Advantage and managed Medicaid populations. * Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. * Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. * MD (Medical Doctor) or DO degree from an accredited medical school. * BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, * Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits * Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts * Financial & Retirement Support - Competitive compensation, 401k with employer match, and financial wellness resources * Time Off & Leave - Paid holidays, flexible vacation time/PSSL, and paid parental leave * Wellness & Growth - Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts 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.

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home model * Value-based care, patient-focused and allows you to spend time with those in your care * Competitive compensation consistent with MGMA guidelines * Comprehensive medical, dental, vision and life insurance * Paid vacation and holiday time * 401(k) plan with matching contributions * Paid relocation assistance- location and case dependent 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here. Roles and Responsibilities * Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment * Counsels and educates patients and families about benefits and programs available to help them live healthier lives * Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan * Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services * Completes all documentation and paperwork in a timely manner * Maintains quality of care standards as defined by the practice * This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state * Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first * Prescribe medications, order tests, and collaborate with patient's Monogram physician * Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily * Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing * Assists patients with enrolling to access educational videos * Participates in the integrated care team meetings * Knowledge of disease diagnosis and prevention * Make assessment of patient's health status * Develop treatment plan * Implement a plan consistent with appropriate plan of care * Follow-up and evaluate patient's status * Other duties as assigned Position Requirements * Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license * Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) * Current and unrestricted DEA certificate * Ability to work without direct supervision and practice autonomously * Access to transportation, a valid driver's license, and car insurance * Must be proficient with medical instruments and equipment required by the work * Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology * Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community * Sound understanding of all federal and state regulations including HIPAA and OSHA * 2 or more years of direct patient care required * Managed Care/IPA/Health Plan experience * Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home

Market Physician Executive (MPE) Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health's Multi[1]Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk[1]based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population healthoutcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution - 25% * Know, understand, and deliver on Monogram Health's proprietary evidenced based clinical pathways. * Ensure adherence to established clinical guidelines and Monogram Model of Care. * Review and approve APP, RN, SW and PharmD plans of care. * Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. * Review, approve and co-sign APP encounters. * Clinical and Operations Performance and Quality Improvement - 25% * Overall accountability for reducing total cost of care and Medical Loss Ratio. * Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient * utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure * Actively lead daily high risk and concurrent review rounds. * Direct supervision of front line clinical and operations team members. * Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. * Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment - 25% * Provide direct and indirect patient care (including diagnosis and treatment of disease). * Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. * Conduct Peer to Peers with community, facility, and health plan partners. * Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) - 20% * Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including * identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete * quality post hospital discharge visits, and improving the quality of visits. * Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. * Present and guide population health strategies in clinical and operational meetings. * Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous - * Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. * Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements * Must be willing and able to obtain hospital privileges at required facilities. * This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. * Demonstrated experience applying evidence based clinical criteria. * Experience in renal care and geriatrics. * Strong management and communication skills. * Active, unrestricted state medical license required in each state within the market. * Experience with high need Medicare Advantage and managed Medicaid populations. * Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. * Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. * MD (Medical Doctor) or DO degree from an accredited medical school. * BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, * Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits * Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts * Financial & Retirement Support - Competitive compensation, 401k with employer match, and financial wellness resources * Time Off & Leave - Paid holidays, flexible vacation time/PSSL, and paid parental leave * Wellness & Growth - Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts 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.

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Flexible scheduling with a hybrid and in-home model Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here. Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first Prescribe medications, order tests, and collaborate with patient's Monogram physician Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Develop treatment plan Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) Current and unrestricted DEA certificate Ability to work without direct supervision and practice autonomously Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required Managed Care/IPA/Health Plan experience Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home

Job DescriptionPosition: Market Physician Executive (MPE) - Augusta GA Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses (RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health's Multi-Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk-based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population health outcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution - 25% Know, understand, and deliver on Monogram Health's proprietary evidenced based clinical pathways. Ensure adherence to established clinical guidelines and Monogram Model of Care. Review and approve APP, RN, SW and PharmD plans of care. Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. Review, approve and co-sign APP encounters. Clinical and Operations Performance and Quality Improvement - 25% Overall accountability for reducing total cost of care and Medical Loss Ratio. Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure. Actively lead daily high risk and concurrent review rounds. Direct supervision of front line clinical and operations team members. Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment - 25% Provide direct and indirect patient care (including diagnosis and treatment of disease). Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. Conduct Peer to Peers with community, facility, and health plan partners. Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) - 20% Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete quality post hospital discharge visits, and improving the quality of visits. Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. Present and guide population health strategies in clinical and operational meetings. Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous - Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements Must be willing and able to obtain hospital privileges at required facilities. This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. Demonstrated experience applying evidence based clinical criteria. Experience in renal care and geriatrics. Strong management and communication skills. Active, unrestricted state medical license required in each state within the market. Experience with high need Medicare Advantage and managed Medicaid populations. Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. MD (Medical Doctor) or DO degree from an accredited medical school. BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care. Competitive salary and opportunity to participate in the company's bonus program. Comprehensive medical, dental, vision and life insurance. Flexible paid leave and 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here.

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits * Flexible scheduling with a hybrid and in-home mode * Value-based care, patient-focused and allows you to spend time with those in your care * Competitive compensation consistent with MGMA guidelines * Comprehensive medical, dental, vision and life insurance * Paid vacation and holiday time * 401(k) plan with matching contributions * Paid relocation assistance- location and case dependent Roles and Responsibilities * Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment * Counsels and educates patients and families about benefits and programs available to help them live healthier lives * Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan * Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services * Completes all documentation and paperwork in a timely manner * Maintains quality of care standards as defined by the practice * This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state * Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first * Prescribe medications, order tests, and collaborate with patient's Monogram physician * Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily * Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing * Assists patients with enrolling to access educational videos * Participates in the integrated care team meetings * Knowledge of disease diagnosis and prevention * Make assessment of patient's health status * Develop treatment plan * Implement a plan consistent with appropriate plan of care * Follow-up and evaluate patient's status * Other duties as assigned Position Requirements * Bilingual (English/Spanish) highly preferred * Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. * Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license * Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) * Current and unrestricted DEA certificate * Ability to work without direct supervision and practice autonomously * Access to transportation, a valid driver's license, and car insurance * Must be proficient with medical instruments and equipment required by the work * Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology * Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community * Sound understanding of all federal and state regulations including HIPAA and OSHA * 2 or more years of direct patient care required * Managed Care/IPA/Health Plan experience * Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home 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.

Job DescriptionPosition: Market Physician Executive (MPE) - Athens, GA Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses (RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health's Multi-Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk-based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population health outcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution - 25% Know, understand, and deliver on Monogram Health's proprietary evidenced based clinical pathways. Ensure adherence to established clinical guidelines and Monogram Model of Care. Review and approve APP, RN, SW and PharmD plans of care. Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. Review, approve and co-sign APP encounters. Clinical and Operations Performance and Quality Improvement - 25% Overall accountability for reducing total cost of care and Medical Loss Ratio. Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure. Actively lead daily high risk and concurrent review rounds. Direct supervision of front line clinical and operations team members. Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment - 25% Provide direct and indirect patient care (including diagnosis and treatment of disease). Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. Conduct Peer to Peers with community, facility, and health plan partners. Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) - 20% Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete quality post hospital discharge visits, and improving the quality of visits. Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. Present and guide population health strategies in clinical and operational meetings. Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous - Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements Must be willing and able to obtain hospital privileges at required facilities. This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. Demonstrated experience applying evidence based clinical criteria. Experience in renal care and geriatrics. Strong management and communication skills. Active, unrestricted state medical license required in each state within the market. Experience with high need Medicare Advantage and managed Medicaid populations. Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. MD (Medical Doctor) or DO degree from an accredited medical school. BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care. Competitive salary and opportunity to participate in the company's bonus program. Comprehensive medical, dental, vision and life insurance. Flexible paid leave and 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024's No. 3 fastest growing private company in the United States, please visit here.

Job Description: Nurse Practitioner Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do. Highlights & Benefits Flexible scheduling with a hybrid and in-home mode Value-based care, patient-focused and allows you to spend time with those in your care Competitive compensation consistent with MGMA guidelines Comprehensive medical, dental, vision and life insurance Paid vacation and holiday time 401(k) plan with matching contributions Paid relocation assistance- location and case dependent Roles and Responsibilities Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first Prescribe medications, order tests, and collaborate with patient's Monogram physician Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Develop treatment plan Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned Position Requirements Bilingual (English/Spanish) highly preferred Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) Current and unrestricted DEA certificate Ability to work without direct supervision and practice autonomously Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required Managed Care/IPA/Health Plan experience Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home 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.