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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 & 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 DescriptionALS United Greater New York is seeking a compassionate, skilled and experienced Licensed Clinical Social Worker/Mental Health Counselor to provide counseling and psychosocial support to patients diagnosed with ALS and their families in New Jersey on a part-time contractual basis. ALS United Greater New York a leader in the fight to treat and cure Amyotrophic Lateral Sclerosis (ALS) by funding cutting edge research and providing vital support services to people with Lou Gehrig’s Disease and their families in the Greater New York area. ALSU is dedicated to enhancing the quality of life for individuals and families affected by ALS. The LCSW (or equivalent) will play a critical role on our Care Service support team, helping patients and caregivers living in New Jersey cope with the emotional, psychological, and social challenges associated with ALS throughout the course of the disease. This is a 1099 independent contractor position, not an employee role. Key Responsibilities: • Provide individual short-term counseling tailored to the unique needs of patients and caregivers., • Develop individualized care plans., • Support patients and families in navigating grief, adjustment to diagnosis, loss of function, depression, anxiety, end-of-life issues, caregiver burnout and family dynamics., • Collaborate with internal team members of Care Services to ensure holistic and patient-centered care., • Maintain timely and accurate clinical documentation in compliance with legal, ethical, and organizational standards. As an independent contractor, candidate must have their own HIPAA-compliant software and telehealth platform., • Provide crisis intervention and short-term problem-solving as needed., • Contribute to program development outreach efforts as part of ALSU’s broader mission.Qualifications:, • Masters degree in Social Work or equivalent from an accredited program, • Active professional license in the state of NJ, • Minimum of 5 years’ experience in medical social work or palliative care. Knowledge of ALS and its psychosocial impacts preferred., • Successful completion of a background check is required., • Holder of professional liability insurance, • Strong skills in empathic communication, crisis intervention, and interdisciplinary collaboration, • Experience working with diverse and underserved populations, • Bilingual preferred Working Conditions:, • Work is typically conducted via telehealth ensuring access for clients across our region, • May require occasional evening hours depending on patient needs, • Must be able to manage intense situations with resilience and professionalism, • This is an independent (1099) contractor position. The contractor is responsible for their own taxes, business expenses, and benefits.·

Job DescriptionPosition: Inpatient Care Manager The Inpatient Care Manager reports directly to the Market Physician Executive (MPE) within their Pod and is responsible for engaging with Monogram’s attributed patients and their families in inpatient facilities. This role’s primary responsibility is to find, engage and enroll new patients in the Monogram program. However, this person will also spend time visiting currently enrolled patients who are hospitalized and provide support with discharge planning or social services. The Inpatient Care Manager might also complete these activities occasionally for patients in outpatient settings, such as dialysis centers or primary care clinics. In all these situations, the Inpatient Care Manager will need to be empathetic, inquisitive and resourceful to identify and solve for the patient’s unique needs. In many instances, this person will need to coordinate with hospital or payer staff to gain access and reach these objectives. The Inpatient Care Manager must be confident and able to overcome barriers to access facilities and patients. This person will attend their Pod’s daily concurrent review rounds, to stay apprised of newly admitted patients and build their work queue for the day. The needs of the Pod’s change frequently so it’s important that the Inpatient Care Manager maintain a tight working relationship with their MPE, Market Administrative Coordinator (MAC) and Clinical Performance Lead (CPL). Roles and Responsibilities • Attends daily concurrent review rounds with Pod clinical leaders and works with their manager to build a daily work queue, • Reviews inpatient and emergency room admission data through Monogram’s care events, • Conducts pre-visit research to better understand each patient’s background and potential needs, • Drives to and finds patients in facilities to engage with them and facilitate enrolling them in the Monogram program, • Assesses patient’s cognitive status to ensure effective communication, and verifies patient identification and contact details for HIPAA compliance, • Articulates Monogram’s services and value in an accurate and compelling manner, while respecting boundaries of the patient and family, • Ability to engage and build rapport with patients, family and caregivers of diverse socio-economic and cultural backgrounds with multiple chronic conditions and vulnerabilities, • Applies evidence-based criteria to determine clinical intervention eligibility and recommend next actions to Pod leadership, as needed, • Identifies social services and discharge planning needs and works with the patient, family and hospital staff to access resources, • Serves as an informational resource for patients and families/caregivers regarding their care plan and available services (hospice care, palliative care, long-term acute care, home care, etc.), • Evaluates patient’s progress and effectiveness of resources or services, making necessary and appropriate changes based upon patient’s status, • Reviews patient consent status and obtains new consent, if required, • Practices within the scope of licensure Position Requirements, • Graduate from an accredited Social Worker or Registered Nurse program of study, • Current active Social Worker or Registered Nurse (unrestricted) licensure, • Minimum of two (2) years’ previous care management experience, • Ability to demonstrate empathy, compassion, and quickly build relationships with patients, family/caregivers, and care teams, including physicians, • Ability to handle rejection and keep trying, while respecting patient’ and families’ boundaries, • Ability to navigate hospital environments, advocate for access and maintain composure when faced with resistance from hospital staff, • Experience assessing vulnerable high-risk patients and advocating for their needs to external staff at hospitals or payers, • Demonstrated verbal and written communication skills, • Previous experience with electronic health record platforms, MS Office Suite, and mobile phone and web-based applications, • Reliable personal transportation, valid driver’s license, and auto insurance, • Must live in the desired geography and be willing to travel 2-3 hours per day to visit patients, • Ability to work independently with minimal supervision as well as part of a team, • Demonstrated initiative and self-starter, • Infrequent domestic travel may be required, primarily to Brentwood, TN Benefits, • Opportunity to work in a dynamic, fast-paced, and innovative care management company that is transforming the delivery of kidney care., • Competitive salary and opportunity to participate in company’s bonus program., • Comprehensive medical, dental, vision and life insurance, • Flexible paid leave & vacation policy 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. 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.