Role Description
Monogram Health is seeking compassionate and skilled Advanced Practice Providers (Nurse Practitioners or Physician Assistants) to deliver high-quality in-home care to patients living with multiple chronic conditions, including:
-
Diabetes
-
Hypertension
-
Chronic kidney disease
-
Heart failure
-
COPD
-
Depression
-
Other complex health needs
This role works within an integrated multidisciplinary care team (Clinical, Behavioral Health, Pharmacy, Administrative), establishing long-term patient relationships and providing continuity of care to complex patients in their homes and via telehealth. The Advanced Practice Provider has the opportunity to be part of a value-based, patient-centered care model, providing quality-driven managed care with a population health focus.
Qualifications
-
Bilingual (Fluent in Spanish, Chinese, Russian, Yiddish or Bengali preferred)
-
Active and unrestricted RN and NP license, or Physician Assistant license
-
Board certification (NP: ANCC/AANP | PA: NCCPA)
-
Current and unrestricted DEA certificate, or eligibility to obtain
-
Minimum 2 years of direct patient care experience
-
Field-based role requiring travel to patient homes, reliable transportation, valid driverโs license, and auto insurance
-
BLS certification (supported during onboarding)
-
Demonstrated initiative and independent, critical thinking, and decision-making skills
-
Knowledge of and compliance with federal/state regulations (HIPAA, OSHA)
-
Previous experience conducting annual wellness or comprehensive visits preferred
-
Prior experience with EHR systems (Athena, Salesforce) preferred
-
Background in managed care, population health, or value-based care preferred
Requirements
-
Provide evidence-based, patient-focused care that reduces avoidable hospitalizations and improves quality of life directly in the patientโs home
-
Perform comprehensive assessments, including initial evaluations, annual wellness exams, follow-ups, and post-discharge visits
-
Educate patients and caregivers on disease management, preventive care, medications, and diagnostic testing
-
Participate in recurring virtual integrated care team meetings
-
Coordinate care with PCPs, specialists, and ancillary services
-
Complete documentation accurately and in a timely manner
-
Periodic travel may be required
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