Patient Health Advocate- VBC

About the Role

Somatus is a leading provider of outcomes‑driven care for individuals and communities living with chronic conditions. The Patient Health Advocate (PHA) supports high‑needs Chronic Kidney Disease (CKD) and End‑Stage Kidney Disease (ESKD) populations, working closely with patients, physician practices, and the Somatus care team in a hybrid telehealth environment.

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

Responsibilities

• Work closely with Somatus patients and physician practices, spending time in physician offices; serve as the primary Somatus representative.
• Build trust and relationships with partnered physicians and practices.
• Support preparation and management of monthly integrated interdisciplinary care team meetings.
• Serve as primary contact for provider practices regarding patient needs and care coordination.
• Follow up with health management plans and goals in coordination with the RNCM.
• Collaborate with provider practices to build and fine‑tune workflows that support operational goals with the RNCM and care team.
• Educate provider practices about the Somatus program and reinforce collaborative workflows.
• Advocate for patients throughout their journeys.
• Conduct patient outreach (telephonic and in‑person) to introduce, align, encourage enrollment, and engage patients.
• Reach out to members in or recently discharged from inpatient settings; connect with Transitions of Care RN for assessment.
• Assist patients during transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Help members schedule follow‑up appointments post‑discharge with their provider.
• Schedule members for initial and subsequent Somatus assessments with the RNCM.
• Document all activities in the care coordination platform in collaboration with physician practices.
• Address language and cultural barriers; coach and guide patients to meet personal and clinical goals.
• Schedule provider appointments on behalf of patients; accompany patients to appointments when needed; remind patients of upcoming appointments.
• Help patients access community and government services and resources.
• Reinforce education about symptom response plans to patients and caregivers.
• Arrange transportation for patients.
• Facilitate closing gaps in care by reinforcing preventive monitoring education and collaborating with physician practices to schedule/complete diagnostic testing.
• Assist patients with access to educational videos.
• Support NP and RNCM care team members by facilitating in‑home telehealth visits with patients.
• Utilize motivational interviewing techniques to encourage behavioral changes.

Qualifications

• High school diploma or equivalent (required).
• 1+ years experience in case management or care management, preferably coordinating care across multiple settings.
• 2+ years healthcare‑related experience.
• Experience working with Medicare, Medicaid, and/or Special Needs populations.
• Experience working in a physician office.
• Preferred: Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to renal patients.
• Preferred: Bilingual in Spanish, Cantonese, or Mandarin with fluent clinical communication.

Skills

• Demonstrated success working as part of a multidisciplinary team, communicating with physicians and registered nurses.
• Effective written and verbal communication with respect and cultural awareness.
• Computer proficiency with MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices; ability to type and talk simultaneously while navigating multiple applications.
• Ability to obtain a valid BLS certification from the American Heart Association or Red Cross as needed.
• Proven experience engaging patients in healthy behavior changes.
• Proven skills navigating health systems and making necessary linkages to meet specific needs.
• Ability to consult with physicians and team members to ensure care plan implementation.
• Active participation in Care Management Coordination Committee (CMCC) meetings.
• Core values consistent with a patient‑centered approach to care.
• Ability to adapt to changing work environments based on member and client needs.
• Adherence to departmental policies and procedures.
• Self‑motivated with a strong work ethic.

Physical Requirements

• Reside in a location with high‑speed internet and a private, dedicated home workspace free from distractions to protect patient privacy (HIPAA).
• Ability to travel throughout the assigned region for home, provider, or facility visits as needed.
• Ability to work the assigned schedule to meet client and patient needs.
• Ability to remain seated or standing for extended periods as required.

Compensation

$20.00 to $24.00 per hour, with competitive compensation reflecting market conditions, skills, experience, and geographic location. Compensation may vary based on qualifications, competencies, and other factors.