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<h3>Job Description</h3>
Job DescriptionPosition: Palliative Care Nurse Practitioner 
Monogram Health is seeking a full-time Palliative Care Advanced Practice Provider (APP) to join the team to support our rapid nationwide growth. This Palliative Care APP will be an in-market provider delivering in-home care for a highly complex patient population in their community, including end-of-life patients with CKD/ESRD, diabetes, COPD, and CHF. The Palliative Care APP will support the Market Physician Executive, the Palliative Care Lead Physician, and an interdisciplinary team to provide palliative care, clinical guidance to patients and their families, including pain and symptom management, develop appropriate care plans and document advance directives to ensure patient-centered care.
Your Impact
Palliative Care APPs are quality-driven clinicians who apply their expertise in a managed care, population health context. They also engage in population health management in a sophisticated, outcomes-driven manner that promotes palliative care where clinically appropriate and focuses on patient quality of life, education, and shared-decision making. 
They will collaborate with our interdisciplinary Pod teams and field clinicians to enhance care integration and optimize palliative care delivery to complex patients through Monogram Health’s comprehensive polychronic care model.
Highlights &amp; Benefits 
<ul>
<li>Flexible scheduling</li>
<li>Opportunity to work in a dynamic, fast-paced and innovative organization that is transforming the delivery of polychronic disease care </li>
<li>Competitive salary plus company bonus program </li>
<li>Full benefits including medical, dental, vision and life insurance </li>
<li>Paid time off and 401(k) with matching contributions</li>
</ul>
Roles &amp; Responsibilities 
<ul>
<li>Collaborate with the Market Physician Executive and clinical leaders including Palliative Care physician to proactively identify patients who qualify for palliative care services and build a patient panel</li>
<li>Develop individualized care plans in collaboration with Market Physician Executive and other clinical leaders including Palliative Care physician to ensure patients are placed on appropriate evidence-based interventions and pathways</li>
<li>Provide compassionate, patient-centric palliative care primarily through in-home visits, with virtual care as needed, to support outcomes and care in alignment with patient’s goals</li>
<li>Evaluate and treat symptoms that may interfere with quality of life, like pain, pruritus, depression, anxiety, insomnia, etc. </li>
<li>Collaborate with pharmacists and other clinicians to manage medication panels for complex patients  </li>
<li>Provide resources and educate patients and their families on the progression of CKD, ESKD, and related conditions, including treatment options and palliative care principles</li>
<li>Help families navigate complex medical decisions and improve understanding of prognosis, including advance care planning to discuss values, goals of care, and document patient/family wishes in state AD/POLST forms </li>
<li>Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first </li>
<li>Support patients utilizing our interdisciplinary team, including Palliative Care Chaplain</li>
<li>Assist with transition to hospice care as appropriate </li>
<li>Participate in monthly meetings with clinical leadership to drive Program KPIs and support execution of clinical and financial goals</li>
<li>Educate and support team members on palliative care, hospice care, advance directives, symptom assessment, and communication</li>
<li>As needed for patient care, conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment </li>
<li>Counsels and educates patients and families about benefits and programs available to help them live healthier lives </li>
<li>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. Completes all documentation and paperwork in a timely manner </li>
<li>Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services </li>
<li>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 </li>
<li>Prescribe medications, order tests, and collaborate with patient’s Monogram physician </li>
<li>Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily </li>
<li>Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing </li>
<li>Assists patients with enrolling to access educational videos </li>
<li>Participates in the integrated care team meetings </li>
<li>Make assessment of patient's health status and develop treatment plan </li>
<li>Implement a plan consistent with patient’ goals of appropriate plan of care </li>
<li>Follow-up and evaluate patient's status </li>
<li>Other duties as assigned </li>
</ul>
Minimum Qualifications
<ul>
<li>Active and unrestricted Nurse Practitioner or Physician Assistant license </li>
<li>Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA) </li>
<li>Current and unrestricted DEA certificate </li>
<li>Ability to work without direct supervision and practice autonomously </li>
<li>Must possess reliable transportation and the ability to travel within the designated region to meet patient needs including in-home and clinic visits as needed. Access to transportation, a valid driver's license, and car insurance </li>
<li>Active state-specific licensure and willingness to become licensed in multiple states as company and patient needs require</li>
<li>2+ years working with patients in a palliative care setting; other relevant experience will be considered</li>
</ul>
Preferred Qualifications
<ul>
<li>Is certified in ACHPN or CHPN</li>
<li>Demonstrated experience in clinical assessment, care plan design, and evaluating patients using evidence-based clinical criteria </li>
<li>Strong communication skills for sensitive conversations about prognosis and end-of life decisions including goals of care discussions and advance care planning</li>
<li>Proficiency with electronic health record (EHR) systems to document complex case details</li>
</ul>
 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.

Palliative Nurse Practitioner

<h3>Job Description</h3>
Job DescriptionJob 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 &amp; Benefits  
<ul>
<li>Flexible scheduling with a hybrid and in-home model</li>
<li>Competitive compensation and a performance-based bonus program</li>
<li>Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time</li>
</ul>
Roles and Responsibilities
<ul>
<li>Work closely with patients’ medical providers to develop and continually adapt care plan</li>
<li>Perform in-home care management visits to execute care management plan</li>
<li>Monitor biometric data and follow approved protocols for any necessary interventions</li>
<li>Inventory and reconcile medications and coordinate with pharmacists and prescribers</li>
<li>Perform patient health assessments and surveys as required</li>
<li>Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities</li>
<li>Encourage medication and treatment adherence through frequent contact with patients</li>
<li>Engage family and social support groups in the education and care of patients</li>
<li>Serve as the primary point of contact and be the first call when patients have questions (business hours)</li>
<li>Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices</li>
<li>Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities</li>
<li>Obtain vital signs when visiting patient and escalate any concerns to the provider</li>
<li>Initiate patient relationships through enrolment and onboarding processes</li>
<li>Perform post-op and hospital discharge visits to help patients through vulnerable transitions</li>
<li>Review and document patient updates and progress in care management platform</li>
<li>Coordinate with dialysis providers to ensure transitions of care are seamless</li>
</ul>
Position Requirements
<ul>
<li>Frequent local travel to perform in-home visits</li>
<li>Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding</li>
<li>Infrequent domestic travel may be required, primarily to Brentwood, TN for training</li>
<li>Self-starter with the ability to work independently with minimal supervision</li>
<li>Ability to show empathy and quickly build relationships with patients and physicians</li>
<li>Graduate of an accredited School of Nursing</li>
<li>Currently licensed as a Registered Nurse in the State of the posted location</li>
<li>2+ years previous experience working in care management and/or with CKD/ESRD patients</li>
<li>Ability to take call remotely on some nights and weekends</li>
<li>Excellent verbal communication skills both in person and on the phone</li>
<li>Familiarity with Microsoft Office and mobile phone and web-based applications</li>
</ul>
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.

Care Manager - Registered Nurse

<h3>Job Description</h3>
Job DescriptionJob 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 &amp; Benefits  
<ul>
<li>Flexible scheduling with a hybrid and in-home mode</li>
<li>Value-based care, patient-focused and allows you to spend time with those in your care</li>
<li>Competitive compensation consistent with MGMA guidelines</li>
<li>Comprehensive medical, dental, vision and life insurance</li>
<li>Paid vacation and holiday time</li>
<li>401(k) plan with matching contributions</li>
<li>Paid relocation assistance- location and case dependent</li>
</ul>
Roles and Responsibilities
<ul>
<li>Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment </li>
<li>Counsels and educates patients and families about benefits and programs available to help them live healthier lives</li>
<li>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</li>
<li>Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services</li>
<li>Completes all documentation and paperwork in a timely manner</li>
<li>Maintains quality of care standards as defined by the practice</li>
<li>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</li>
<li>Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first</li>
<li>Prescribe medications, order tests, and collaborate with patient’s Monogram physician </li>
<li>Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily</li>
<li>Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing</li>
<li>Assists patients with enrolling to access educational videos</li>
<li>Participates in the integrated care team meetings</li>
<li>Knowledge of disease diagnosis and prevention</li>
<li>Make assessment of patient's health status</li>
<li>Develop treatment plan</li>
<li>Implement a plan consistent with appropriate plan of care</li>
<li>Follow-up and evaluate patient's status</li>
<li>Other duties as assigned  </li>
</ul>
Position Requirements
<ul>
<li>Bilingual (English/Spanish) highly preferred</li>
<li>Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. </li>
<li>Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license</li>
<li>Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA)</li>
<li>Current and unrestricted DEA certificate</li>
<li>Ability to work without direct supervision and practice autonomously</li>
<li>Access to transportation, a valid driver's license, and car insurance</li>
<li>Must be proficient with medical instruments and equipment required by the work</li>
<li>Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology</li>
<li>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 </li>
<li>Sound understanding of all federal and state regulations including HIPAA and OSHA</li>
<li>2 or more years of direct patient care required</li>
<li>Managed Care/IPA/Health Plan experience</li>
<li>Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home </li>
</ul>
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.

Nurse Practitioner

<h3>Job Description</h3>
Job DescriptionDescription:
Bring your passion for helping seniors to The Marquardt, an Illuminus Community!
 
Every day, CNAs have the opportunity to make a meaningful difference in the lives of our residents, fostering genuine connections and creating vibrant communities where seniors can thrive.
 
Offering a sign on bonus up to $600!
$19.06 - $22.50 per hour (based on experience)
Enjoy a $2 shift differential for our PM and NOC shifts
 
CURRENT SCHEDULING NEEDS:
Part-time and Full-time
<ul>
<li>AM Shift - 6:00am - 2:00pm</li>
<li>PM Shift - 2:00pm - 10:00pm</li>
<li>NOC Shift - 10:00pm - 6:00am</li>
</ul>
JOB SUMMARY:
The Certified Nursing Assistant performs person centered personal cares for the resident under the supervision of a licensed nurse.
 
BENEFITS:
From competitive pay and health insurance coverage to retirement plans and paid time off, we prioritize the needs of our team members and ensure they feel valued and appreciated.
 
CAREER PATH SUPPORT:
If you aspire to further your education and become a Licensed Practical Nurse (LPN) or Registered Nurse (RN), we’re committed to supporting your growth by providing tuition reimbursement.
Requirements:
<ul>
<li>Commitment to quality outcomes and services for all individuals.</li>
<li>Ability to relate well to all individuals.</li>
<li>Ability to maintain and protect the confidentiality of information.</li>
<li>Ability to exercise independent judgment and make sound decisions.</li>
<li>Ability to adapt to change.</li>
</ul>
EXPERIENCE AND TRAINING:
<ul>
<li>At least 16 years of age.</li>
<li>Be current on the Wisconsin Nurse Aide Registry.</li>
</ul>
About Us
The Marquardt, an Illuminus Community, is set on a 52-acre campus with rolling green lawns, gorgeous trees and flowers and paved walkways. The Marquardt offers assisted living, memory care, and skilled nursing care as well as independent living options for older adults in Garden Homes and apartments.
 
Established in 1969, The Marquardt has continued to transform expectations of senior living with ever-evolving and expansive options in Watertown, Wisconsin, conveniently located halfway between Madison and Milwaukee.
 
Illuminus is a faith-based, not-for-profit senior living management company dedicated to serving older adults and families throughout the Midwest with skill and compassion. We own or manage over a dozen communities in Wisconsin and beyond, offering independent senior housing, assisted living and memory care, skilled nursing and rehabilitation, low-income senior housing, home health and hospice services via Commonheart management support and consulting.
 
The people of Illuminus are not just our colleagues, our employees, our residents—they are our parents, our grandparents, our partners, ourselves. We serve others with gratitude, dignity, hope and purpose. We believe that the right care can and will transform us all.
#IlluminusCNA

Certified Nursing Assistant CNA at The Marquardt

Care Manager - Registered Nurse - Rock Hill, SC

<h3>Job Description</h3>
Job DescriptionJob 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 &amp; Benefits  
<ul>
<li>$130k starting salary </li>
<li>Sign On Bonus </li>
<li>Flexible scheduling with a hybrid and in-home mode</li>
<li>Value-based care, patient-focused and allows you to spend time with those in your care</li>
<li>Competitive compensation consistent with MGMA guidelines</li>
<li>Comprehensive medical, dental, vision and life insurance</li>
<li>Paid vacation and holiday time</li>
<li>401(k) plan with matching contributions</li>
<li>Paid relocation assistance- location and case dependent</li>
</ul>
Roles and Responsibilities
<ul>
<li>Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment </li>
<li>Counsels and educates patients and families about benefits and programs available to help them live healthier lives</li>
<li>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</li>
<li>Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services</li>
<li>Completes all documentation and paperwork in a timely manner</li>
<li>Maintains quality of care standards as defined by the practice</li>
<li>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</li>
<li>Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first</li>
<li>Prescribe medications, order tests, and collaborate with patient’s Monogram physician </li>
<li>Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily</li>
<li>Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing</li>
<li>Assists patients with enrolling to access educational videos</li>
<li>Participates in the integrated care team meetings</li>
<li>Knowledge of disease diagnosis and prevention</li>
<li>Make assessment of patient's health status</li>
<li>Develop treatment plan</li>
<li>Implement a plan consistent with appropriate plan of care</li>
<li>Follow-up and evaluate patient's status</li>
<li>Other duties as assigned  </li>
</ul>
Position Requirements
<ul>
<li>Bilingual (English/Spanish) highly preferred</li>
<li>Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. </li>
<li>Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license</li>
<li>Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA)</li>
<li>Current and unrestricted DEA certificate</li>
<li>Ability to work without direct supervision and practice autonomously</li>
<li>Access to transportation, a valid driver's license, and car insurance</li>
<li>Must be proficient with medical instruments and equipment required by the work</li>
<li>Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology</li>
<li>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 </li>
<li>Sound understanding of all federal and state regulations including HIPAA and OSHA</li>
<li>2 or more years of direct patient care required</li>
<li>Managed Care/IPA/Health Plan experience</li>
<li>Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home </li>
</ul>
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.

Nurse Practitioner - Sign On Bonus Offered

<h3>Job Description</h3>
Job DescriptionJob Description: Care Manager, Social Worker
Monogram Health is looking for skilled Social Worker eager for the opportunity to make a difference in patients' lives. The Care Manager Social Worker is a key member of an integrated Care Team which includes a Nurse Care Manager and an Advanced Practice Provider. The patients we serve often struggle with multiple serious diseases and behavioral health challenges. Social workers can remove the many economic and behavioral barriers to patients, enabling positive health outcomes. 
Your Impact 
The care team works with patients face-to-face, over the phone, and through telehealth to identify and address social determinants of health. The goal is to build a patient’s social support network, navigate behavioral challenges, and generally help patients through a traumatic diagnosis and life-changing disease. 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 &amp; Benefits    
<ul>
<li>Remote opportunity with some occasional local travel</li>
<li>The ability to work directly with patients and build meaningful relationships</li>
<li>Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time</li>
</ul>
Roles and Responsibilities
<ul>
<li>Perform in-home and telehealth care management visits to assess and determine social and behavioral status </li>
<li>Work closely with Care Team to ensure collaboration and optimal patient outcomes</li>
<li>Assess social determinants of health needs and develop a plan for addressing them</li>
<li>Identify, vet, and build relationships with local Community-Based Organizations </li>
<li>Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes</li>
<li>Serve as subject matter expert on social determinants for other members of the Care Team </li>
<li>Complete behavioral, environmental, and social support assessments</li>
<li>Deliver individual, family and group education on living with chronic illness </li>
<li>Engage family and social support groups in the education and care of patients </li>
<li>Assess patients and refer to behavioral health specialists if diagnosis and treatment needed </li>
<li>Help patients to understand, accept and follow medical and lifestyle recommendations </li>
<li>Review and document patient updates and progress in care management platform </li>
</ul>
Position Requirements 
<ul>
<li>This position involves telephonic visits with some car travel to patients’ homes </li>
<li>Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. </li>
<li>Currently licensed as a LCSW or LMSW in the posted state </li>
<li>Master’s degree in social work and passed ASWB masters or clinical exam</li>
<li>Rare domestic travel may be required to Brentwood, TN </li>
<li>Self-starter with the ability to work independently with minimal supervision </li>
<li>Ability to show empathy and quickly build relationships with patients and local CBOs </li>
<li>Preferred 2+ years previous experience working in care management and/or with chronic illness </li>
<li>Excellent verbal communication skills both in person and on the phone </li>
<li>Familiarity with Microsoft Office and mobile phone and web-based applications </li>
</ul>
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.

Care Manager - Social Worker

<h3>Job Description</h3>
Job DescriptionDescription:
We are looking for a part-time (2 days/week, flexible) PCP to support our Bronx Clinic. Our clinic serves adults with developmental disabilities, and is open Monday-Friday, 9am-4:30pm.
 
Why Join ADAPT?
It's more than a job; it's a calling. It's where passion meets purpose. ADAPT Community Network, formerly United Cerebral Palsy (UCP) of NYC provides a multitude of services to people with developmental disabilities. At ADAPT, we are 3,000 strong, and it takes every one of us to empower the lives of the people we support. With caring and great resources at hand, we know what it takes to help people live fuller, happier, healthier lives. Our employees show their commitment to the people we support every day, and we all deliver on our promise to provide innovative and comprehensive services to individuals with developmental disabilities.
For your next career move, apply with us at ADAPT Community Network! Wherever you work among our many locations around New York City, ADAPT offers paid training, competitive benefits, and we foster a team culture of learning, support, collaboration and career growth.
 
SUMMARY
Under the general direction of the Medical Director, the Physician provides high-quality, person-centered medical care to patients in ADAPT Community Network’s clinics and programs. This role is responsible for diagnosing, treating, and managing medical conditions while ensuring continuity of care, regulatory compliance, and collaboration with interdisciplinary teams. The Physician will also contribute to health promotion, disease prevention, and the integration of medical services that enhance the well-being of individuals supported by the organization.
 
ESSENTIAL DUTIES AND RESPONSIBILITIES
The duties and responsibilities of the Physician will include, but are not limited to, the following:
<ul>
<li>Conducts comprehensive patient evaluations, including history taking, physical examinations, and preventive health assessments.</li>
<li>Diagnoses and manages acute, chronic, and complex medical conditions in alignment with evidence-based practices.</li>
<li>Prescribes medications, orders diagnostic tests (laboratory, radiologic, and specialized exams), and develops treatment plans.</li>
<li>Administers vaccinations and immunizations in accordance with guidelines and patient needs.</li>
<li>Coordinates care with Nurse Practitioners, RN Case Managers, and other members of the healthcare team to ensure continuity and follow-up.</li>
<li>Refers patients to specialists and facilitates emergency care when appropriate.</li>
<li>Provides health education, counseling, and preventative guidance to patients and families.</li>
<li>Reviews and maintains accurate, timely, and complete medical records, including encounter documentation and treatment plans.</li>
<li>Collaborates with day programs, residential services, family members, and service coordinators to support holistic patient care.</li>
<li>Ensures compliance with federal, state, and local regulations as well as organizational policies and procedures.</li>
<li>Participates in quality improvement initiatives, case reviews, and audits to strengthen patient outcomes and clinical excellence.</li>
<li>Supervises and mentors medical students, residents, or fellows as assigned.</li>
<li>Maintains current knowledge of medical advancements, treatment standards, and best practices in community-based care.</li>
<li>Performs other related duties and special projects as assigned.</li>
</ul>
 
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
<ul>
<li>Strong clinical, diagnostic, and problem-solving skills with the ability to manage diverse patient populations.</li>
<li>Excellent interpersonal and communication skills, with the ability to collaborate effectively with patients, families, and interdisciplinary teams.</li>
<li>Commitment to person-centered care, cultural competence, and equitable healthcare practices.</li>
<li>Ability to maintain strict confidentiality and exercise sound judgment in sensitive situations.</li>
<li>Proficienct in electronic health records (EHR) and related medical technologies.</li>
<li>Strong organizational and time management skills, with the ability to work independently and manage multiple priorities.</li>
</ul>
 
EDUCATION and/or EXPERIENCE
<ul>
<li>Graduate of an accredited medical school.</li>
<li>Completion of residency training in family medicine, internal medicine, or related specialty.</li>
<li>Minimum of three (3) years of experience as a practicing physician, preferably in a community-based or nonprofit healthcare setting.</li>
</ul>
 
LICENSES/CERTIFICATIONS
<ul>
<li>Current and valid New York State Physician’s License required.</li>
<li>Board certification (or board eligibility) in Family Medicine, Internal Medicine, or related specialty preferred.</li>
<li>Current CPR/BLS certification required.</li>
</ul>
COMPENSATION: $125/hour
 
At ADAPT, we value diversity, equity, inclusion, accessibility, and belonging. We strive to ensure that our employees are comfortable bringing their whole, authentic self to work and that the people we support can also be their authentic selves. We value diverse backgrounds, opinions, ideas, and ways of thinking. We aim to build an inclusive and diverse workforce that is empowered and supported with leaders who create diverse and inclusive teams. We continuously seek opportunities for the organization to foster a more positive, respected, united, and collaborative culture.
 
ADAPT Community Network is proud to be an equal opportunity employer and is committed to creating an inclusive environment for all employees. Qualified candidates of diverse ethnic and racial backgrounds and status are encouraged to apply for vacant positions at all levels.
Requirements:

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