Patient Health Advocate- VBC

As a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus is helping patients across the country enjoy More Healthy Days at Home™. Care at Somatus goes beyond treatment through a whole-person approach, delivering integrated care and showing 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.

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, including spending time working from within physician offices as the first and primary representative of Somatus, responsible for establishing trust and building relationships
• Support the preparation and management of regular integrated, interdisciplinary care team meetings each month
• Serve as primary contact for provider practice regarding patient needs and care coordination
• Follow-up with health management plans and goals in coordination with the RNCM
• Collaborate with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team
• Educate the provider practice about the Somatus program, reinforcing collaborative workflows
• Function as an advocate for the patient and support patients throughout their journeys
• Conduct patient outreach (telephonic and in-person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients
• Conduct outreach to members currently or recently in the inpatient setting to engage in the Somatus program and/or connect with a Transitions of Care RN to complete an assessment
• Assist patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions
• Assist members in scheduling appointments for follow-up post-discharge from the inpatient setting with their provider
• Schedule members for initial and subsequent Somatus assessments with the RNCM
• Use the care coordination platform to document all activities in collaboration with physician practices
• Engage with patients who need assistance with self-care needs, such as:
  • Address language and cultural barriers to care management and self-care
  • Coach and guide the patient to meet both personal and clinical goals
  • Schedule provider appointments on behalf of patients
  • Accompany patients to their appointments when needed
  • Remind patients of their upcoming appointments
  • Help patients access community and government-based services and resources
  • Reinforce education provided to the patient and/or caregiver about symptom response plans
  • Arrange transportation
  • Facilitate closing gaps in care by reinforcing education to patients about preventive monitoring 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 patients to make behavioral changes

Requirements

• High school diploma or equivalent required
• 1+ years of 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

Qualifications

• Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to Renal patients (preferred)
• Bilingual in either Spanish, Cantonese, or Mandarin, with the ability to converse fluently in a clinical setting using clinical terms (preferred)

Skills

• Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Physicians and Registered Nurses
• Effective written and verbal communication skills that demonstrate respect and cultural awareness during interactions with patients and clients
• Computer proficiency utilizing MS Office (Word, Excel, PowerPoint, and Outlook), and telecom devices including the ability to type and talk at the same time while navigating multiple applications
• Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility as needed
• Proven experience with engaging patients in making healthy behavior changes
• Proven skills in navigating the health systems and making necessary linkages to meet specific needs
• Ability to consult with physicians and other team members to ensure that care plan is successfully implemented
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings
• Core values consistent with a patient-centered approach to care
• Ability to adapt to changing work environment based on member and client needs
• Adheres to departmental policies and procedures
• Self-motivated with a strong work ethic

Schedule

• Hybrid Telehealth environment with a combination of remote days and visits to members’ homes
• Works under the guidance of practice physicians and/or a nurse care manager
• Ability to work the assigned schedule to meet the client and patient's needs
• Ability to travel throughout the assigned region to conduct home, provider, or facility visits, based on the assigned market needs

Physical Requirements

• Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service
• Access to a private, dedicated home workspace free from distractions to protect patient privacy regarding HIPAA and Privacy regulations
• Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

For this position, we require proof of COVID-19 vaccination, annual Influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB for employment.