Nurse Practitioner - Detroit, OH

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?

Our name, Monogram, symbolizes the personalized focus of our services.

While the application of the latest technology and data science is critical to our success, we never lose sight that healthcare is ultimately about trusted individual relationships between healthcare professionals and their patients.

Unfortunately, individuals living with advanced CKD and ESRD are negatively impacted by well entrenched systematic forces such as perverse economic incentives, poor adherence to evidence-based care, and a lack of sensitivity to the negative impacts of social determinants of health.

The 21st Century Cures Act is a seminal piece of legislation designed to shift individuals living with ESRD from FFS Medicare into managed care and reverse decades and decades of sub-optimal outcomes. Monogram was born with a vision to serve health plans and other sponsors of health care and solve for these systemic problems.  Our mission is to improve clinical outcomes by predicting the onset of CKD and ESRD, slowing its progression, and reducing hospitalizations, morbidity and mortality.

We are founded and operated by a core group of former government programs health plan executives, including our CEO, Michael Uchrin, a world-renown nephrologist and author of over 200 published pieces of research, Dr. Raymond Hakim, and former US Senator Bill Frist M.D., a retired cardiac surgeon and recognized leader for improving the quality of care provided to human beings across the world.

We welcome all stakeholders in the CKD | ESRD ecosystem to join us in our mission to measurably improve outcomes for individuals living with these conditions.