Monogram Health

Role Description The IT Project Manager is responsible for planning, executing, and closing projects that support Monogram Health’s client implementations and ongoing operational initiatives. This role manages scope, timelines, resources, risks, and communication across stakeholders to ensure consistent, high-quality delivery. The ideal candidate is detail-oriented, proactive, and skilled at balancing multiple priorities in a fast-paced environment. They collaborate closely with internal teams and external partners to ensure deliverables, reporting, and milestones are met to support positive outcomes and strong client satisfaction. This role is eligible for telecommuting in accordance with company policy. - Create, maintain, and manage project plans, schedules, deliverables, RAID logs, and milestones. - Monitor project quality, scope, and progress; escalate risks and issues with recommendations for resolution. - Track contractual requirements to ensure all deliverables and reports are timely, accurate, and aligned with client expectations. - Support the implementation of effective and repeatable project management processes to drive consistent outcomes. - Collaborate with internal stakeholders across Clinical Performance, Market Leadership, IT, Analytics, Data Engineering, Clinical App Development, Data Science, and other relevant teams to ensure alignment and timely execution. - Coordinate resources across internal teams and vendors in support of project tasks and timelines. - Facilitate the definition and documentation of workflows, requirements, and process improvements. - Communicate the project status, risks, dependencies, and changes to stakeholders with clarity and professionalism. - Tailor communication to audiences at varying levels, ensuring transparency and shared understanding. - Partner with cross-workstreams to support timely decision-making and issue resolution. - Evaluate deliverables for quality and completeness; ensure readiness for client submission. - Maintain up-to-date documentation of IT and business processes related to client requirements. - Foster a positive, collaborative, and supportive work environment that aligns with Monogram Health’s culture of empathy, care, and patient-centered service. Qualifications - Bachelor’s degree in information technology, Business, or related field. - Minimum of three (3) years of progressive experience in project or program management, leading complex technology, data, systems, or client-facing initiatives across multiple organizational domains. - Experience working alongside health plans, delegated service providers, clinical operations, or dialysis organizations is highly valued. - Proven experience coordinating with IT teams or technical stakeholders. - Core project management skills (planning, execution, scope management, scheduling, quality management, risk management), including organization, prioritization, and time management skills. - Demonstrated interpersonal skills; able to adjust messaging based on audience and engage effectively across workstreams. - High proficiency in Microsoft Excel, Word, PowerPoint, and project management (Smartsheet a plus); ability to synthesize data into executive-ready reporting. - Detail-oriented with strong problem-solving skills. Benefits - Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts. - Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources. - Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave. - Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts. Company Description 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.

Role Description The MH FIRST Remote RN - Float is pivotal in providing critical support to field teams facing urgent and complex patient concerns. The RN Float has expertise that will ensure patients receive the care, resources, and support they need, especially during high-stress situations and environmental crises. - Utilize licensing and crisis management skills to assess and address urgent needs. - Assess care plan requirements and assist in their implementation. - Utilize proficiency in documentation and technology to streamline member care. - Offer valuable support and guidance to patients and their families in critical situations. - Primary point of contact for patients, Monogram field staff, and care center personnel needing immediate support. - Provide seamless transitions by providing comprehensive handoffs to incoming staff. - Conduct chart auditing during non-peak call volumes. - Emergency/disaster outreach as events occur. - Support service level agreement (SLA) compliance for annual assessments and care plans. - Assist in post-hospital outreach to ensure patient needs are met, with no outstanding needs that could result in readmissions. Qualifications - Maintain a current and valid RN license, allowing you to practice across state lines. - Minimum of 3 years of clinical nursing experience, with a preference for emergency care, critical care, or triage backgrounds. - Availability to adjust shift flexibly in response to peak coverage or staffing needs. - Demonstrate the ability to communicate calmly and confidently during high-stress situations. - Build strong relationships with team members and patients through effective rapport-building. - Exhibit meticulous attention to detail and outstanding organizational skills. - Show unwavering dedication to patient safety and delivering high-quality care. Benefits - Opportunity to work in a value-based provider organization revolutionizing kidney care delivery. - Competitive salary that recognizes your expertise and commitment. - Access to various benefits, including medical, dental, vision, and life insurance. - Flexible paid leave and vacation policy that supports your well-being. - 401(k) plan with matching contributions for your financial future. - Explore career opportunities in a company dedicated to providing high-quality care. Company Description 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.

Role Description 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. - Administering follow-up appointments to patients as required. - Working as a team with physician specialists, field-based nurses, community health workers, and physicians. - Conducting patient health assessments and creating strategies to improve or manage patient health for cardiac conditions. - Introducing habits for health promotion. - Conducting physical exams, ordering tests, prescribing medications, and serving as a coordinator with the patient's primary healthcare provider and their specialists. Qualifications - Active and unrestricted Registered Nurse and Nurse Practitioner license. - Board certified by ANCC or AANP. - Current and unrestricted DEA certificate. - Minimum of 2 years of experience as an NP working in an inpatient or outpatient pulmonology setting (no new graduates). - Strong background in patient assessment, diagnosis, treatment, and management of pulmonology diseases. - Excellent communication skills, works well in a team environment, and is adaptable. Requirements - Ability to work without direct supervision and practice autonomously. - 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. Benefits - The base salary range for this role is $102,000 to $169,000, reflecting the range of experience and qualifications considered. - Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. - Eligible for additional compensation, including bonus opportunities and a comprehensive benefits package. - Opportunity to work in a dynamic, fast-paced, and innovative value-based provider organization. - Comprehensive medical, dental, vision, and life insurance. - Flexible paid leave and vacation policy. - 401(k) plan with matching contributions.

Role Description Under the supervision of the lead Staff Software Engineer, the Software Engineer II role will be a driving force in shaping the future of our clinical and patient facing applications. As a key player, you’ll have the opportunity to tackle challenging technical problems, drive solution design, and take advantage of working from within a greenfield environment. You are expected to think critically, be curious, and collaborate with our development teams and stakeholders to ensure we build the best product possible. If you are a highly motivated, adaptive individual with a passion for building software, we encourage you to apply for this unique role. This role supports a fully remote work team, with the expectation you are able to work CST or EST hours. Roles and Responsibilities - Develop software! - Work within a collaborative engineering team utilizing an agile process. - Provide technical guidance and mentoring to offshore team. - Participate in defining scope, objectives, technical direction and be able to independently analyze and design implementations. - Collaborate with business partners to provide recommendations for technology decisions for complex healthcare integrations. - Establish, maintain, and ensure compliance with standards and procedures for design, development, testing, documentation, and CI/CD, contributing to high quality, secure, and reliable systems that meet our business needs. - Work closely with cross-functional teams, including other developers, business analysts, and product owners, to understand project requirements. - Identify opportunities for process improvement within the Engineering process, create buy in and enact positive change. - Exhibit excellent time management, organizational, and prioritization skills and an ability to balance and fulfill multiple priorities. - Performs other duties as assigned. Qualifications - BS, BA in Information Technology, Computer Science, Engineering etc. or equivalent work experience - 4+ years of prior work experience as a software engineer or similar role. - Strong knowledge of software development methodologies and OO design patterns - 2+ years of hands on experience with Dotnet Core and/or .NET Framework, C# - 2+ years of experience with Web API (including minimal API), Azure functions, and Entity Framework preferred - 1+ years of experience with React or similar technologies - 1+ years of experience with Azure - 1+ years of experience with messaging-based solutions like Event Hub - SQL server experience required. - Excellent communication and interpersonal skills, with the ability to work effectively in cross-functional teams. - Strong problem-solving and critical thinking abilities. - Experience with healthcare industry preferred - Familiarity with HL7, FHIR, etc., is nice to have Benefits - Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of poly chronic care - Competitive salary and opportunity to participate in the company’s bonus program - Comprehensive medical, dental, vision and life insurance - Flexible paid leave and vacation policy - 401(k) plan with matching contributions Company Description 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.

Role Description We are seeking a highly motivated Clinical Performance Lead to support our clinicians and front-line staff in caring for our members affected by renal disease. As a Clinical Performance Lead, you’ll play a vital role at Monogram Health. We are looking for a proactive individual that can help us continually improve and enhance our clinical performance. Roles and Responsibilities - Clinical Interventions – 30% - Review, update, and manage clinical interventions (CI), ad hoc tasking, and messages concerning visits. - Document CIs, coach and assist RNs on information needed for tasks. - Make calls to members or physicians to complete tasks. - Review Care Manager documentation for CI. - Review Holy Grail for records to complete tasks. - Assist APPs with requests and help with SalesForce. - Review appropriate sources for records of high-risk members/post-discharge members. - Perform concurrent review hospital calls. - Conduct root cause analysis on certain members. - Attend leadership meetings as needed. - Delegate action to the Patient Support Specialist team to request and receive office visit records. - Patient Care and Treatment – 15% - Review and approve care plans. - Discuss patient care with field clinicians and provide support and guidance. - Facilitate case rounds, PPA clinical rounds, and high-utilizer review. - Execute scheduling needs for high risk, high utilizer members. - Perform data analysis, such as data mining for records lab. - Address concerns and requests from Pod leadership. - Speak and document member conversations as needed. - Delegate action to the PSS team to request and receive prescriptions and labs for review. - Quality Assurance and Compliance – 30% - Delegate action to the PSS team to request and receive labs results for review. - Audit medical charts and review missing team visit notes. - Conduct data analysis from various downloaded reports. - Daily review of documentation and provide guidance on IEs & PHDV. - Review and correct care plans to ensure compliance with SLA. - Provide Bullet Train care coordination. - Provide support to field team for escalations, clinical issues, patient outreach, and RR follow up calls. - Training and Communication – 25% - Provide guidance and education on processes, workflows, and documentation to field staff. - Attend standard and ad-hoc operational meetings. - Prepare slides and content for operational and clinical meetings. - Assist with scheduling needs, Teams chats, emails, and phone calls. - Build reports for specific members and their needs. Qualifications - Current, active unrestricted license as a Registered Nurse in assigned states/territories. - Minimum 2-years of Registered Nurse experience within the last 5 years, or equivalent clinical experience. - Demonstrated knowledge and proficiency using technology. Benefits - Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts. - Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources. - Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave. - Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts. Company Description 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. - Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines. - Available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. - Proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.

Role Description The Software Engineer II role will be a driving force in shaping the future of our clinical and patient-facing applications. As a key player, you will have the opportunity to tackle challenging technical problems, drive solution design, and take advantage of working from within a greenfield environment. You are expected to think critically, be curious, and collaborate with our development teams and stakeholders to ensure we build the best product possible. If you are a highly motivated, adaptive individual with a passion for building software, we encourage you to apply for this unique role. This role supports a fully remote work team, with the expectation of being able to work in Central or Eastern time hours. Responsibilities - Work within a collaborative engineering team utilizing an agile process. - Provide technical guidance and mentoring to offshore team. - Participate in defining scope, objectives, technical direction and be able to independently analyze and design implementations. - Collaborate with business partners to provide recommendations for technology decisions for complex healthcare integrations. - Establish, maintain, and ensure compliance with standards and procedures for design, development, testing, documentation, and Cl/CD, contributing to high quality, secure, and reliable systems that meet our business needs. - Work closely with cross-functional teams, including other developers, business analysts, and product owners, to understand project requirements. - Identify opportunities for process improvement within the Engineering process, create buy in and enact positive change. - Exhibit time management, organizational, and prioritization skills and an ability to balance and fulfill multiple priorities. Qualifications - Bachelor’s degree in information technology, Computer Science, Engineering etc. or equivalent work experience. - Minimum of four (4) years of prior work experience as a software engineer or similar role, which includes experience with WebAPI, Dotnet Core, .NET Framework, C#, React or similar technologies, Azure, SQL, and messaging-based solutions. - Demonstrated communication and interpersonal skills, with the ability to work effectively in cross-functional teams. - Evidence of problem-solving and critical thinking abilities. - Experience with healthcare industry preferred. - Familiarity with HL7, FHIR, etc. preferred. Benefits - Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts. - Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources. - Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave. - Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts. Company Description 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.

Role Description We are seeking a highly motivated Clinical Performance Lead to support our clinicians and front-line staff in caring for our members affected by renal disease. As a Clinical Performance Lead, you’ll play a vital role at Monogram Health. We are looking for a proactive individual that can help us continually improve and enhance our clinical performance. Roles and Responsibilities - Clinical Interventions – 30% - Review, update, and manage clinical interventions (CI), ad hoc tasking, and messages concerning visits. - Document CIs, coach and assist RNs on information needed for tasks. - Make calls to members or physicians to complete tasks. - Review Care Manager documentation for CI. - Review Holy Grail for records to complete tasks. - Assist APPs with requests and help with SalesForce. - Review appropriate sources for records of high-risk members/post-discharge members. - Perform concurrent review hospital calls. - Conduct root cause analysis on certain members. - Attend leadership meetings, as needed. - Delegate action to the Patient Support Specialist team to request and receive office visit records for review. - Patient Care and Treatment – 15% - Review and approve care plans. - Discuss patient care with field clinicians and provide support and guidance. - Facilitate case rounds, PPA clinical rounds, and high-utilizer review. - Execute scheduling needs for high risk, high utilizer members. - Perform data analysis, such as data mining for records lab. - Address concerns and requests from Pod leadership. - Speak and document member conversations as needed. - Delegate action to the PSS team to request and receive prescriptions and labs for review. - Quality Assurance and Compliance – 30% - Delegate action to the PSS team to request and receive labs results for review. - Audit medical charts and review missing team visit notes. - Conduct data analysis from various downloaded reports and create data spreadsheets. - Daily review of documentation and provide guidance on IEs & PHDV. - Review and correct care plans to ensure compliance with SLA. - Provide Bullet Train care coordination. - Provide support to field team for escalations, clinical issues, patient outreach, and RR follow up calls. - Training and Communication – 25% - Provide guidance and education on processes, workflows, and documentation to field staff. - Attend standard and ad-hoc operational meetings. - Prepare slides and content for standard and ad-hoc operational and clinical meetings. - Assist with scheduling needs, Teams chats, emails, and phone calls. - Build reports for specific members and their needs. Qualifications - Current, active unrestricted license as a Registered Nurse in assigned states/territories. - Minimum 2-years of Registered Nurse experience within the last 5 years, or equivalent clinical experience. - Demonstrated knowledge and proficiency using technology. Benefits - Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts. - Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources. - Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave. - Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts. Company Description 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. - Employs a robust clinical team, leveraging specialists across multiple disciplines. - Available 24 hours a day, 7 days a week, and on holidays. - Proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.

Role Description Monogram Health is seeking a healthcare Licensing Specialist with experience in a large clinical organization, provider group, third-party licensing company, or medical staff office. This role supports organizational and clinical goals by ensuring timely, accurate, and compliant licensure of practitioners across multiple states. The Licensing Specialist manages state medical licensure for physicians and advanced practice providers, maintains accurate records in credentialing systems, and proactively resolves discrepancies that could delay licensure. Assignments are driven by business needs and operational/clinical leadership priorities. This role serves as a subject matter expert on state licensure requirements and collaborative practice agreements and always ensures audit-ready documentation. Responsibilities - Manage state licensure, DEA, CDS, and collaborative practice agreements for physicians and other practitioner types (e.g., NPs, RNs, LCSWs). - Prepare clear instructions and correspondence to guide practitioners through application completion and supporting documentation. - Proactively follow up and create urgency with practitioners, institutions, and state boards via phone and email to meet start dates and resolve outstanding items. - Coordinate and submit required primary source verifications to state boards. - Prioritize application workflows based on business needs and departmental guidance. - Track licensure progress, document lifecycle milestones, and maintain accurate, timely data in credentialing systems and shared drives. - Communicate licensure status and expected timeframes to Licensing & Credentialing, Operations, and Clinical Leadership. - Notify Credentialing of license issuances, renewals, and CPA submissions to avoid disruptions in credentialing or enrollment. - Generate reports, monitor expiring licenses and certifications, and manage renewals. - Perform recurring audits, data reconciliation, and reporting; escalate issues as needed. - Ensure practitioner data accuracy across HR, CME, CVO, and credentialing databases. - Maintain confidentiality and adhere to Monogram Health credentialing policies. Qualifications - High school diploma or GED required; bachelor’s degree preferred. - Minimum of three (3) years of licensing experience required. - Proficiency in Microsoft office applications (e.g. Word, Excel, PowerPoint) and Smartsheet. - Proven ability to maintain accuracy and thoroughness in all tasks. - Creative and persistent problem solver. - Ability to research data and draw conclusions. - Must be able to work in an independent manner while also collaborating effectively with team members to manage multiple simultaneous time-sensitive deliverables and deadlines. - Demonstrated capability to engage professionally & effectively with a variety of contacts including senior management, government agencies/licensing board and other business associates. - Highly effective communicator, both in verbal and written communication skills. - Client service oriented. - Attention to detail with a consistent focus on producing accurate work. - Able to handle confidential information in a reliable manner. - Interpersonal skills to handle sensitive situations and confidential information. Benefits - Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts. - Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources. - Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave. - Wellness & Growth: Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts.

Position: Palliative Care Nurse Practitioner - Jacksonville- FL 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. Roles & Responsibilities  - 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 - 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 - 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 - Evaluate and treat symptoms that may interfere with quality of life, like pain, pruritus, depression, anxiety, insomnia, etc.  - Collaborate with pharmacists and other clinicians to manage medication panels for complex patients   - Provide resources and educate patients and their families on the progression of CKD, ESKD, and related conditions, including treatment options and palliative care principles - 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  - Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first - Support patients utilizing our interdisciplinary team, including Palliative Care Chaplain - Assist with transition to hospice care as appropriate  - Participate in monthly meetings with clinical leadership to drive Program KPIs and support execution of clinical and financial goals - Educate and support team members on palliative care, hospice care, advance directives, symptom assessment, and communication - 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 - 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 - Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services - 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 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 - Make assessment of patient's health status and develop treatment plan - Implement a plan consistent with patient’ goals of appropriate plan of care - Follow-up and evaluate patient's status - Other duties as assigned Minimum Qualifications - Active and unrestricted 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 - 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 - Active state-specific licensure and willingness to become licensed in multiple states as company and patient needs require - 2+ years working with patients in a palliative care setting; other relevant experience will be considered Preferred Qualifications - Is certified in ACHPN or CHPN - Demonstrated experience in clinical assessment, care plan design, and evaluating patients using evidence-based clinical criteria  - Strong communication skills for sensitive conversations about prognosis and end-of life decisions including goals of care discussions and advance care planning - Proficiency with electronic health record (EHR) systems to document complex case details Benefits - Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts - Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources - Time Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave - Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts 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. #LI-BG1 #LI-Onsite

Position: Market Physician Executive (MPE) - Float Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients. The MPE will lead our in-home multi-specialty polychronic care model in an assigned market. Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD). The MPE will collaborate with Monogram Health’s Multi[1]Specialty Platform to leverage employed specialists to deliver in-home specialty care. Monogram Health deploys a proven risk[1]based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care. Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population healthoutcomes, provider satisfaction and lower costs. The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment. Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market. The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market. In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients. The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making. Roles and Responsibilities Clinical Guidelines Execution – 25% - Know, understand, and deliver on Monogram Health’s proprietary evidenced based clinical pathways. - Ensure adherence to established clinical guidelines and Monogram Model of Care. - Review and approve APP, RN, SW and PharmD plans of care. - Appropriate and timely patient document within Salesforce and Athena clinical activities, interventions, and tasks. - Review, approve and co-sign APP encounters. - Clinical and Operations Performance and Quality Improvement – 25% - Overall accountability for reducing total cost of care and Medical Loss Ratio. - Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient - utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure - Actively lead daily high risk and concurrent review rounds. - Direct supervision of front line clinical and operations team members. - Oversee and delegate operational responsibility to Market Manager, to deliver on daily operations, such as patient engagement, scheduling, administrative oversight, strategic implementations, and P&L management. - Regularly assess and present market performance and outcomes to Executive and Senior Leaders . Patient Care and Treatment – 25% - Provide direct and indirect patient care (including diagnosis and treatment of disease). - Engage with patients on treatment plans, community provider collaboration, and direct evidence-based care pathways. - Conduct Peer to Peers with community, facility, and health plan partners. - Order labs, referrals, and complete actions to drive patient outcomes, close care gaps, and Clinical Intervention closure. Population Health Management (PHM) – 20% - Provide clinical guidance and direction to Market teams to drive Population Health Management activities, including - identifying and intervening on High-Risk Patients, formulating strategies to reduce admissions/readmissions, complete - quality post hospital discharge visits, and improving the quality of visits. - Collaborate with Medical Economics, Finance and other stakeholders to root cause and action against utilization trends impacting care and outcomes. - Present and guide population health strategies in clinical and operational meetings. - Conduct patient reviews to target high utilizers, high risk and high opportunity patients and patient cohorts. Miscellaneous – <5% - Participate in Monogram On-Call activities Needs will vary; 7 days on call minimum once/quarter. - Provide coverage for other MPEs, during PTO or vacancy, as needed. Position Requirements - Must be willing and able to obtain hospital privileges at required facilities. - This position will be remote within the designated market with occasional in-home patient treatment visits and occasional domestic travel. - Demonstrated experience applying evidence based clinical criteria. - Experience in renal care and geriatrics. - Strong management and communication skills. - Active, unrestricted state medical license required in each state within the market. - Experience with high need Medicare Advantage and managed Medicaid populations. - Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. - Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Willingness to become licensed in multiple states. - MD (Medical Doctor) or DO degree from an accredited medical school. - BC or BE in an ACGME approved specialty such as Nephrology, Internal Medicine, Family Practice, Emergency Medicine, - Critical Care, Cardiology, Endocrinology, Hepatology, or Geriatrics. Benefits - Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts - Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources - Time Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave - Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts 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.