Monogram Health

General

• Serve as liaison between patients and Pod clinicians
• Schedule patient visits within the structured visit cadence
• Ensure Post-Hospital Discharge Visits are scheduled within 72 hours of patient discharge
• Scrub clinician calendars for the following week to ensure quality visits and optimize field staff calendars
• Outreach patients with missed visits within the last three days to reschedule visits
• Reassign visits for unavailable clinicians according to scheduling criteria
• Perform Pod assignments delegated by the direct supervisor
• Provide coverage to other Pods or Regions and adjust schedule as needed
• Participate in Pod huddles with the Market Manager, MAC, and POD leadership
• Troubleshoot field clinician scheduling concerns and execute patient engagement or re-engagement tactics
• Report directly to the POD Market Manager and take direction from POD leadership

Pod Engagement Specialist

• Serve as liaison between patients and Pod clinicians
• Schedule patient visits within the structured visit cadence
• Ensure Post-Hospital Discharge Visits are scheduled within 72 hours of patient discharge
• Scrub clinician calendars for the following week to ensure quality visits and optimize field staff calendars
• Contact patients with missed visits within the last three days to reschedule visits
• Reassign visits for unavailable clinicians, including clinicians who are out of office, transferred roles, or left the company
• Perform delegated Pod assignments as needed
• Provide coverage to other Pods and regions based on business needs, with possible schedule changes
• Participate in Pod huddles with the Market Manager, MAC, and Pod leadership
• Troubleshoot field clinician scheduling concerns and perform patient engagement or re-engagement activities
• Report directly to the POD Market Manager and follow direction from POD leadership
• Interact with peers, other departments, Pod leadership, Monogram Health leaders, patients, and internal and external customers

Physician

• Care for seriously ill patients in their community, primarily in the home
• Collaborate with the Market Physician Executive and care team to identify patients qualifying for palliative care services and build a patient panel
• Develop and present metrics to executive leadership as requested
• Drive clinical and financial KPIs for the patient panel through defined interventions
• Treat patients in-home to drive healthcare outcomes
• Evaluate and treat symptoms affecting quality of life, including pain, pruritis, depression, anxiety, and insomnia
• Refer members to appropriate Monogram-based or locally aligned specialists
• Conduct goals-of-care and family meetings and document patient/family wishes in state AD/POLST forms
• Support patients through the interdisciplinary team, including Palliative Care Chaplain
• Assist with hospice transitions as appropriate
• Develop relationships with local providers to improve market alignment
• Participate in monthly KPI and expectations meetings with RMD/CMO
• Educate and support the team around palliative care, hospice care, advance directives, symptom assessment, and communication

Lead Palliative Care Physician

Nurse Practitioner

• Provide personalized, compassionate medical care to underserved patients, primarily with CKD through ESRD
• Travel throughout the assigned territory to conduct in-home assessments, annual wellness exams, focused screenings, and other visits in patients' homes and virtually
• Travel out of state for up to 2 weeks at a time as necessary
• Counsel and educate patients and families about benefits, programs, preventive care, and prescribed treatments
• Document chief complaints, diagnoses, medical histories, reviews of systems, examinations, medications, allergies, assessments, and plans
• Coordinate care with primary care providers, specialists, and ancillary services
• Complete documentation and paperwork in a timely manner
• Maintain quality-of-care standards
• Deliver evidence-based care to reduce avoidable hospitalizations and maximize quality of life
• Prescribe medications, order tests, and collaborate with Monogram physicians
• Monitor and report patient quality outcomes daily
• Close gaps in care through preventive-monitoring education and scheduling diagnostic testing
• Assist patients with enrolling to access educational videos
• Participate in integrated care team meetings
• Assess patient health status, develop and implement treatment plans, and follow up on patient status
• Perform other duties as assigned

Travel Nurse Practitioner

Program Manager

• Serve as the day-to-day operational lead of one or more specialty care programs
• Plan, manage, and continuously improve operational workflows for assigned specialty programs
• Own clinician scheduling infrastructure, monitor utilization, identify capacity gaps, and drive scheduling adjustments
• Serve as the primary operational point of contact for assigned clinical teams
• Manage team support needs and maintain accurate program and clinician records
• Monitor program-level and clinician-level performance metrics, surface patterns, and escalate risks
• Support interviewing, onboarding, and training clinical staff
• Maintain onboarding documentation and program knowledge management infrastructure
• Develop operational playbooks, best-practice documentation, and job aids
• Translate leadership priorities into structured workplans and manage dependencies
• Partner cross-functionally with IT, data analytics, clinical operations, and other teams
• Develop and maintain operational dashboards and reporting in Salesforce and PowerBI
• Update clinician-facing tools as fields, workflows, or program requirements change
• Create executive-ready materials for program updates and leadership reporting
• Monitor operational KPIs and use data to recommend process improvements
• Identify and close gaps in documentation, reporting, and workflow coverage
• Leverage AI tools such as Claude to enhance productivity, automate repeatable tasks, and improve documentation

Program Manager – Specialty Programs

• Provide comprehensive, personalized medical care to underserved patients, primarily with CKD through ESRD
• Travel throughout the assigned territory to conduct in-home assessments, annual wellness exams, focused screenings, and virtual visits
• Travel out of state for up to 2 weeks at a time as necessary
• Counsel and educate patients and families about benefits, programs, preventative care, and prescribed treatments
• Document chief complaints, diagnoses, medical histories, reviews of systems, examinations, medications, allergies, assessments, and care plans
• Coordinate care with primary care providers, specialists, ancillary services, and the patient's Monogram physician
• Complete documentation and paperwork in a timely manner
• Maintain quality-of-care standards
• Deliver evidence-based care to reduce avoidable hospitalizations and improve quality of life and patient satisfaction
• Prescribe medications and order tests
• Measure and report patient quality outcomes daily
• Close gaps in care through preventive-monitoring education and coordination of diagnostic testing
• Assist patients with enrolling to access educational videos
• Participate in integrated care team meetings
• Assess patients' health status, develop and implement treatment plans, and evaluate follow-up status
• Perform other duties as assigned

Travel Nurse Practitioner / Physician Assistant

Outside Sales

• Conduct daily in-person outreach to high-risk, hard-to-reach patients by visiting their homes unannounced
• Educate patients in person about the Monogram Health program
• Schedule and complete at least 15 home visits daily
• Drive a designated territory daily to engage new and existing members
• Meet or exceed sales targets and KPIs
• Facilitate a high completion rate of scheduled visits
• Collaborate with internal sales and marketing teams to optimize outreach strategies
• Maintain accurate records in CRM systems
• Build trust with potential members and connect them to Monogram Health’s in-home care services

Field Sales Representative

• Conduct daily in-person outreach to high-risk, hard-to-reach patients by visiting their homes unannounced
• Educate patients in person about the Monogram Health program
• Proactively schedule and complete at least 15 home visits daily
• Drive a designated territory daily to engage new and existing members
• Meet or exceed sales targets and KPIs
• Facilitate a high completion rate of scheduled visits
• Collaborate with internal sales and marketing teams to optimize outreach strategies
• Maintain accurate records in CRM systems
• Build trust with potential members and connect them to Monogram Health’s in-home care services

• Conduct daily in-person outreach to high-risk, hard-to-reach patients by visiting their homes unannounced
• Educate patients in person about the Monogram Health program
• Proactively schedule and complete at least 15 home visits daily
• Drive a designated territory daily to engage new and existing members
• Meet or exceed sales targets and KPIs
• Facilitate a high completion rate of scheduled visits
• Collaborate with internal sales and marketing teams to optimize outreach strategies
• Maintain accurate records in CRM systems

• Conduct daily in-person outreach to high-risk, hard-to-reach patients by visiting their homes unannounced
• Educate patients in person about the Monogram Health program
• Proactively schedule and complete at least 15 home visits daily
• Drive a designated territory daily to engage new and existing members
• Meet or exceed sales targets and KPIs
• Facilitate a high completion rate of scheduled visits
• Collaborate with internal sales and marketing teams to optimize outreach strategies
• Maintain accurate records in CRM systems
• Engage face-to-face with Monogram-eligible patients not currently enrolled
• Answer patient questions and build trust to connect patients with care

• Deliver evidence-based, patient-focused care in patients’ homes and via telehealth
• Reduce avoidable hospitalizations and improve quality of life
• Perform comprehensive assessments, initial evaluations, annual wellness exams, follow-ups, acute urgent visits, 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
• Conduct quality assurance activities, audits, and documentation reviews
• Practice in skilled nursing facilities, assisted living facilities, hospitals, and other affiliated clinical settings as applicable
• Perform point-of-care A1C and spirometry testing
• Prescribe medications and order tests
• Collaborate with the patient’s Monogram physician
• Coordinate care with PCPs, specialists, and ancillary services
• Complete documentation accurately and promptly
• Establish long-term patient relationships and provide continuity of care within a multidisciplinary team

Nurse Practitioner / Physician Assistant

• Conduct daily in-person outreach to high-risk, hard-to-reach patients by visiting their homes unannounced
• Educate patients in person about the Monogram Health program
• Schedule and complete at least 15 home visits daily
• Drive a designated territory daily to engage new and existing members
• Meet or exceed sales targets and KPIs
• Facilitate a high completion rate of scheduled visits
• Collaborate with internal sales and marketing teams to optimize outreach strategies
• Maintain accurate records in CRM systems
• Build trust with potential members and connect eligible patients to Monogram Health’s in-home chronic-care services

Manager

• Direct administrative supervision of Travel Team operations
• Coordinate travel assignments with market leaders to optimize Travel APP support for Market Operations
• Manage staff capacity, productivity, and quality
• Manage scheduling efforts and oversee scheduling systems, processes, and performance
• Lead daily, weekly, and monthly team meetings alongside the physician counterpart
• Develop reports, conduct data analysis, and determine root causes for team KPIs and trends
• Lead clinical operations between market, regional, and centralized cross-functional stakeholders
• Ensure the integrity, timeliness, and quality of clinical documentation in Monogram Health’s EMRs
• Manage, monitor, and report compliance risks, issues, and concerns
• Be accountable for patient experience (NPS)
• Support talent acquisition, interviewing, and hiring of clinical and operations team members
• Onboard, train, and support development paths for field-based team members
• Manage licensing and credentialing needs for multi-state licensed Travel APPs
• Achieve company organizational key results and key performance indicators
• Champion change, implement strategic priorities, optimize operations, deliver results, and drive great culture

Pod Engagement Specialist

Pod Engagement Specialist

Lead Palliative Care Physician

Travel Nurse Practitioner

Program Manager – Specialty Programs

Travel Nurse Practitioner / Physician Assistant

Field Sales Representative

Field Sales Representative

Field Sales Representative

Field Sales Representative

Field Sales Representative

Field Sales Representative

Nurse Practitioner / Physician Assistant

Field Sales Representative

Travel Team Manager