Patient Health Advocate- VBC

How We Show Up For Our Patients

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, 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.

How We’ll Support You

• 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

How You'll Make An Impact

The Patient Health Advocate (PHA) role supports Somatus high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations that face multiple challenges, from accessing resources to adhering to a physician’s treatment plan. The PHA for VBC will work closely with Somatus patients and physician practices, including spending time working from within physician offices and will be the first and primary representative of Somatus, responsible for establishing trust and building relationships with the partnered physician’s and practices.

• Works under the guidance of practice physicians and/or a nurse care manager.
• Partners closely with physicians and practice office staff to build a positive, collaborative relationship focused on working together to improve care for patients, support clinical and operational goals, and improves Somatus’ primary representative in the practice.
• Serves as primary contact for provider practice regarding patient needs and care coordination.
• Follows up with health management plans and goals in coordination with the RNCM.
• Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.
• Educates the provider practice about the Somatus program, reinforcing collaborative workflows.
• Serves as an advocate for the patient and supports the patients throughout their journeys.
• Conducts patient outreach (i.e., telephonic and in-person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients.
• Conducts 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.
• Aids patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Aids members in scheduling appointments for follow-up post-discharge from the inpatient setting with their provider.
• Schedules members for initial and subsequent Somatus assessments with the RNCM.
• Uses the care coordination platform to document all activities in collaboration with physician practices.
• Engages 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 their patients.
• Accompany patients to their appointments when needed.
• Remind patients of their upcoming appointments.
• Help patients access community and government-based services and resources.
• Help 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.
• Aid 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.

Qualifications

• 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.

Preferred Qualifications

• Bilingual in either Spanish, Cantonese, or Mandarin, with the ability to converse fluently in a clinical setting using clinical terms.

Core Values

• Consistent with a patient-centered approach to care.
• Adaptable to changing work environment based on member and client needs.
• Self-motivated with a strong work ethic.
• 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 travel throughout the assigned region to conduct home, provider, or facility visits, based on the assigned market needs; Ability to work the assigned schedule to meet the client and patient's needs; Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions.

Physical Requirements

• Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions.

Reasonable Accommodations

• May be made to enable individuals with disabilities to perform the essential functions.

Our Commitment To Diversity

• We celebrate what makes us unique — our people. We believe that a culture intentionally built to foster and support our unique passions, experiences, and perspectives helps fuel us in the pursuit of our mission.
• Somatus, Inc. provides equal employment opportunity to all individuals regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by law. Discrimination of any type will not be tolerated.