Patient Health Advocate

About the role

As the largest and leading value-based kidney care company, Somatus empowers patients living with chronic kidney disease to live more days out of the hospital and healthier at home. The CHW-Patient Advocate position focuses on high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations facing multiple challenges.

Responsibilities

• Work as an extension of the clinical care team, guided by an RN Care Manager.
• Manage caseload through in-person, telephonic, and electronic communications and coordination.
• Facilitate initial wellness exams and care management assessments with Somatus clinicians.
• Connect patients with various resources within and beyond Somatus, including the care team, PCPs, nephrologists, and community services.
• Engage with patients to address self-care needs, language and cultural barriers, and coach them towards achieving personal and clinical goals.
• Schedule and accompany patients to appointments, remind them of upcoming appointments, and assist with accessing community and government-based services.
• Facilitate closing gaps in care by educating patients about preventive monitoring and coordinating diagnostic testing.
• Absorb and educate patients about educational videos provided by Somatus.
• Participate in integrated care team meetings and support the member's patient journey, starting with initial outreach.
• Conduct telephonic outreach to members within designated geographic areas to introduce the Somatus program and encourage enrollment.
• Support NP and RNCM care team members by facilitating in-home telehealth visits with patients.
• Utilize motivational interviewing techniques to encourage patients to make behavioral changes.

Requirements

• Experience working with Medicare, Medicaid, or Special Needs populations.
• Medical Assistant, Licensed Practical Nurse, Engagement Specialist, or Community Health Worker experience.
• Ability to connect with people and understand their challenges.
• Effective written and verbal communication skills, demonstrating respect and cultural awareness.
• Well-connected to the community and resources within the community they will serve.
• Comfortable with conducting home visits (50-75% same-day travel).
• Great motivator, organized, empathetic, outgoing, and positive personality.

Qualifications

• Experience working with patients with chronic and behavioral health needs.
• Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Physicians and Registered Nurses.
• Proven experience in engaging patients in making healthy behavior changes.
• Proven skills in navigating the health systems and making necessary linkages to meet specific needs.
• Experience working with Electronic Medical Records and other documentation platforms.

Skills

• Strong interpersonal and communication skills.
• Ability to navigate and utilize various outreach methods.
• Knowledge of chronic and end-stage kidney disease management.
• Experience with motivational interviewing techniques.

Benefits

Subsidized, personal healthcare coverage (medical, dental, vision), accrual of 3 weeks' vacation (PTO), professional development, CEU, and tuition reimbursement, curated wellness benefits, community engagement opportunities, and more!

Pay

$21.00- $25.00 per hour, compensation may vary based on qualifications, skills, and experience.

Schedule

Hybrid Telehealth environment with a combination of remote days and visits to members’ homes.