Pulmonary Advanced Practice Provider - Central

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 seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. 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.

The Monogram Pulmonary Nurse Practitioner will be responsible for the delivery of personalized compassionate medical care to patients primarily with COPD and other pulmonary conditions. The Nurse Practitioner will be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. The successful candidate will work as a team with our physician specialists, field-based nurses, community health workers, and physicians and assist in delivering premium care to every patient. Primary duties include patient health assessment, creating strategies to improve or manage a patient health for cardiac conditions, and introduce habits for health promotion. He/she may also conduct physical exams, order tests, prescribe medications, and serve as a coordinator with the patient's primary healthcare provider and their specialists.

Work with COPD patients to ensure medication compliance, monitoring dietary and lifestyle changes, regular follow ups and care coordination. Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first. Work collaboratively with the Pulmonologist and staff to provide high quality, patient centered care. Work closely with pulmonology team, other specialist teams, and clinical care teams. Conducts assessments 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. 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. Prescribe medications, order tests, and collaborate with patient’s Monogram pulmonologist and physician. Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily. 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.