Nurse Practitioner - Lake Jackson, TX

Job Description

Job Description

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.

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.

• 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

• 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  

• 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 

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.