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Job Description: Nurse PractitionerMonogram 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 ImpactUsing 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 & BenefitsFlexible scheduling with a hybrid and in-home modeValue-based care, patient-focused and allows you to spend time with those in your careCompetitive compensation consistent with MGMA guidelinesComprehensive medical, dental, vision and life insurancePaid vacation and holiday time401(k) plan with matching contributionsPaid relocation assistance- location and case dependentAbout Monogram HealthMonogram 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 ResponsibilitiesConducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environmentCounsels and educates patients and families about benefits and programs available to help them live healthier livesDocuments items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and planResponsible for the coordination of care with primary care providers, specialists, and appropriate ancillary servicesCompletes all documentation and paperwork in a timely mannerMaintains quality of care standards as defined by the practiceThis 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 stateDeliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction firstPrescribe medications, order tests, and collaborate with patient's Monogram physicianPerform effectively, as reflected by improved patient quality outcomes, which will be measured and reported dailyFacilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testingAssists patients with enrolling to access educational videosParticipates in the integrated care team meetingsKnowledge of disease diagnosis and preventionMake assessment of patient's health statusDevelop treatment planImplement a plan consistent with appropriate plan of careFollow-up and evaluate patient's statusOther duties as assignedPosition RequirementsBilingual (English/Spanish) highly preferredActive and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant licenseBoard certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA)Current and unrestricted DEA certificateAbility to work without direct supervision and practice autonomouslyAccess to transportation, a valid driver's license, and car insuranceMust be proficient with medical instruments and equipment required by the workKnowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technologyAbility to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the communitySound understanding of all federal and state regulations including HIPAA and OSHA2 or more years of direct patient care requiredManaged Care/IPA/Health Plan experienceExperience conducting annual wellness visits or similar comprehensive visits virtually or in the home