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The Care Manager RN works within an integrated team to develop and execute in-home care plans for patients with serious chronic diseases. Responsibilities include monitoring biometric data, reconciling medications, providing patient education, and facilitating transitions of care.
Job Description: Care manager – registered nurse
Monogram Health is looking for skilled Registered Nurse eager for the opportunity to make a difference in patients' lives. The Care Manager RN is a key member of an integrated Care Team which includes an Advanced Practice Provider and a Social Worker. The patients we serve often struggle with multiple serious diseases. Registered Nurses help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes.
Your Impact
As a Registered Nurse, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can directly experience the impact of your care. 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.
Roles and responsibilities
Work closely with patients’ medical providers to develop and continually adapt care plan
Perform in-home care management visits to execute care management plan
Monitor biometric data and follow approved protocols for any necessary interventions
Care Manager RN
Inventory and reconcile medications and coordinate with pharmacists and prescribers
Perform patient health assessments and surveys as required
Deliver individual and group education on CKD, ESRD, dialysis and associated comorbidities
Encourage medication and treatment adherence through frequent contact with patients
Engage family and social support groups in the education and care of patients
Serve as the primary point of contact and be the first call when patients have questions (business hours)
Provide education and coaching around medications, medical conditions, diet, exercise, and lifestyle choices
Educate patients and facilitate conversations around proactive care decisions, especially relating to Advance Care Plans and ESRD treatment modalities
Obtain vital signs when visiting patient and escalate any concerns to the provider
Initiate patient relationships through enrolment and onboarding processes
Perform post-op and hospital discharge visits to help patients through vulnerable transitions
Review and document patient updates and progress in care management platform
Coordinate with dialysis providers to ensure transitions of care are seamless
Position requirements
Frequent local travel to perform in-home visits
Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding
Infrequent domestic travel may be required, primarily to Brentwood, TN for training
Self-starter with the ability to work independently with minimal supervision
Ability to show empathy and quickly build relationships with patients and physicians
Graduate of an accredited School of Nursing
Currently licensed as a Registered Nurse in the State of the posted location
2+ years previous experience working in care management and/or with CKD/ESRD patients
Ability to take call remotely on some nights and weekends
Excellent verbal communication skills both in person and on the phone
Familiarity with Microsoft Office and mobile phone and web-based applications
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.
Requirements
Candidates must be a graduate of an accredited School of Nursing and hold a current Registered Nurse license in the state of the position. A minimum of 2 years of experience in care management or with CKD/ESRD patients and a Basic Life Support (BLS) certification are required.
professional certificate
Registered Nurse
Communication
Empathy
Basic Life Support
Patient education
Patient assessment
Interdisciplinary collaboration
Care planning
Clinical documentation
Care management
Medication reconciliation
Health coaching
Chronic kidney disease management
Biometric monitoring
Transition of care
Posting details
Employment type
Full Time
Work arrangement
On Site
Experience
2-5 yrs
Location
Cleveland, Ohio
Posted
Aug 31, 2026
Application
Employer website
Market context
Ohio LPN roles remain steady
In Ohio, nursing roles like LPN positions are typically supported by steady demand across clinics, long-term care, and other care settings. Competition often centers on active state licensure, relevant bedside experience, and readiness to work within team-based care environments. Review the AI-summarized requirements and benefits here to save time, then confirm your LPN credential and tailor your application to the settings where you have the strongest experience.
