Nurse Practitioner

Monogram Health • Full-time • Bloomsburg, Pennsylvania, United States • 1w ago

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

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’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.

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
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
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

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