Patient Health Advocate

About the role

Somatus is a leading provider of outcomes‑driven care for individuals and communities living with chronic conditions, helping patients enjoy More Healthy Days at Home. Through a whole‑person approach, we deliver outcomes‑driven integrated care and partner with health plans, health systems, and provider groups to support patients with or at risk of developing cardio, kidney, metabolic, or other chronic conditions. We hire purpose‑driven talent and have grown since 2016, emphasizing culture, clinical excellence, and a #SomatusStrong mindset. This is a market‑based position.

Responsibilities

• Focus on high‑needs Chronic Kidney Disease (CKD) and End‑Stage Kidney Disease (ESKD) populations.
• Act as an extension of the clinical care team under the guidance of an RN Care Manager, serving as the primary patient advocate and relationship holder.
• Manage a caseload via in‑person, telephonic, and electronic communication.
• Schedule the initial wellness exam and care management assessment with Somatus clinicians.
• After a care plan is developed, facilitate connections and scheduling of resources within and beyond Somatus (including PCPs, nephrologists, other care team members).
• Engage in community outreach to connect patients with peers and support overall wellbeing.
• Follow up with health management plans and goals; establish positive, supportive relationships with participants and provide feedback.
• Conduct initial triage assessment to align patients with the appropriate program per guidelines.
• Document activities in the care coordination platform, including care plan activities.
• Assist patients with self‑care needs beyond what a nurse care manager can provide via phone, addressing language and cultural barriers, coaching toward personal and clinical goals.
• Schedule provider appointments on behalf of patients and accompany them when needed.
• Remind patients of upcoming appointments.
• Help patients access community and government‑based services, including assistance with paperwork.
• Teach caregivers about symptom response plans.
• Arrange transportation for patients.
• Facilitate closing gaps in care by educating patients about preventive monitoring