Monogram Health Altoona , PA 16602
Posted 4 weeks ago
Position: Care Manager
Monogram Health Care Managers are in the perfect position to facilitate meaningful improvement in the lives of very ill patients. A significant number of patients with Chronic Kidney Disease and End Stage Renal Disease are economically disadvantaged and lacking the support needed to care for themselves properly, all while often struggling with multiple serious diseases and behavioral health challenges. Care Managers can remove the many economic and behavioral barriers to patients experiencing great health outcomes.
As a key member of a Care Team which includes a Nurse Care Manager and a Care Coordinator, the Care Manager
Roles and Responsibilities
Perform in-home care management visits to assess and impact social and behavioral status
Work closely with Care Team to ensure continual progress on all care management goals
Assess social determinants of health needs and develop a plan for addressing them
Perform behavioral, environmental, and social support assessments and surveys as needed
Deliver individual, family and group education on living with chronic illness
Engage family and social support groups in the education and care of patients
Assess patients and refer to behavioral health specialists if diagnosis and treatment needed
Help patients to understand, accept and follow medical and lifestyle recommendations
Serve as the point of contact for patient questions regarding social and behavioral
Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement
Initiate patient relationships through enrolment and onboarding processes
Review and document patient updates and progress in care management platform
Identify, vet, and build relationships with local Community-Based Organizations
Introduce patients to appropriate resources and act as the patient advocate
Serve as subject matter expert on social determinants for other members of the Care Team
Position Requirements
This position involves car travel to patients' homes
Currently licensed as a LCSW
Rare domestic travel may be required to Brentwood, TN
Self-starter with the ability to work independently with minimal supervision
Ability to show empathy and quickly build relationships with patients and local CBOs
Master's Degree in Social Work, behavioral sciences, or another related field
2+ years previous experience working in care management and/or with chronic illness
Ability to occasionally visit patients or 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
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 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.
Monogram Health