Job Description

Job Description

Job Description

Position: Palliative Care Nurse Practitioner / Physican Assistant

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.

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.

• Flexible scheduling
• Opportunity to work in a dynamic, fast-paced and innovative organization that is transforming the delivery of polychronic disease care
• Competitive salary plus company bonus program 
• Full benefits including medical, dental, vision and life insurance 
• Paid time off and 401(k) with matching contributions

• 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

• 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

• 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

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.

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