Patient Health Advocate

About the role

Care at Somatus goes beyond treatment. Through a whole‑person approach, we deliver outcomes‑driven integrated care and show up #SomatusStrong for our patients and teammates. We partner closely 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 the brightest and boldest — talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn’t just a milestone — it’s a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence.

Responsibilities

• Manage a caseload through in-person, telephonic, and electronic communications and coordination.
• Act as the primary representative of Somatus to members and build trusting patient relationships.
• Schedule initial wellness exams and care management assessment meetings with Somatus clinicians.
• Facilitate connections and scheduling of resources within and beyond Somatus to the patient, including care team members, PCPs, and Nephrologists.
• Engage in the community to connect patients with resources and support overall wellbeing.
• Conduct initial triage assessments to align patients with the most appropriate program in accordance with guidelines.
• Document activities in the care coordination platform, including care plan activities conducted.
• Engage with patients who need assistance with self-care needs beyond what a nurse care manager can provide via phone, including addressing language and cultural barriers to care management and self-care.
• Coach and guide patients to meet personal and clinical goals.
• Schedule provider appointments on behalf of patients and accompany patients to appointments when needed.
• Remind patients of upcoming appointments and help access community and government-based services, including possibly filling out paperwork for the patient.
• Teach caregivers about symptom response plans, arrange transportation, and facilitate closing gaps in care by educating patients about preventive monitoring.
• Work with physician practices to schedule diagnostic testing and assist patients with enrolling to access educational videos.
• Participate in integrated care team meetings and act as the patient advocate supporting members through their patient journey starting with initial outreach.
• Conduct telephonic outreach to members within designated geographic areas to introduce the Somatus program and encourage enrollment to build caseload.
• Conduct door-to-door engagement outreach for patients with telephonic barriers.
• 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.

Measures of Success

• Patient Engagement
• Care Setting Transitions
• Assessment
• Monthly Goal completion as set by the RNCM
• Patient Success — as measured by no/reduced hospital or ER visits on a monthly basis

Requirements

• Experience working with Medicare, Medicaid or Special Needs populations.
• High school diploma or GED required.
• Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker experience.
• Ability to connect with people and understand the challenges they face.
• Ability to use a range of outreach methods to engage individuals and groups in diverse settings.
• Well connected to the community and resources within the community they will serve.
• Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
• Ability to travel throughout the assigned region and comfort with conducting home visits (50–75% same-day travel).

Preferred Qualifications

• Experience working with patients with chronic and behavioral health needs.
• Associate degree or higher from an accredited college preferred.
• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with physicians and registered nurses.
• Proven experience engaging patients in making healthy behavior changes.
• Proven skills in navigating health systems and making necessary linkages to meet specific needs.
• Experience working with Electronic Medical Records and other documentation platforms.

Benefits

• Subsidized personal healthcare coverage: Medical, Dental & Vision, plus Wellness programs
• Paid Time Off: Accrual of 3 weeks’ Vacation (PTO)
• Professional development: CEU and tuition reimbursement

Pay

$21.00 to $24.00 per hour. Compensation for the role will depend on qualifications, skills, competencies, experience, and geographic location and may fall outside of the range shown above.

Schedule

Somatus offers a Hybrid Telehealth environment with a combination of remote days and visits to members’ homes. This position will be focused on high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations and requires 50–75% same-day travel within the assigned region.