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
• 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 driver’s 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 patient’s 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
Company Description
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with complex chronic conditions. Our personalized model addresses the full spectrum of patient needs—clinical, behavioral, social, and environmental. Supported by a multidisciplinary team across nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care, we deliver comprehensive care that improves outcomes, enhances quality of life, and reduces healthcare costs.