Patient Health Advocate- VBC

About the Role

As a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus helps patients across the country enjoy More Healthy Days at Home™. The Patient Health Advocate (PHA) supports high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations facing challenges such as accessing resources and adhering to treatment plans. This role operates in a hybrid telehealth environment, combining remote work with home and provider visits, and serves as the primary representative of Somatus in partnered physician practices.

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 on-site visits to establish trust and build relationships.
• Support the preparation and management of monthly interdisciplinary care team meetings.
• Serve as the primary contact for provider practices regarding patient needs and care coordination.
• Follow up on health management plans and goals in coordination with the Registered Nurse Care Manager (RNCM).
• Collaborate with provider practices to build and refine workflows supporting operational goals.
• Educate provider practices about the Somatus program and reinforce collaborative workflows.
• Conduct patient outreach (telephonic and in-person) to introduce, align, and engage patients in the Somatus program.
• Engage with patients recently discharged from inpatient settings to connect them with Transitions of Care RN for assessments.
• Assist patients during transitions of care to minimize avoidable readmissions and facilitate follow-up appointments.
• 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 patient self-care needs, including:
  • Language and cultural barriers to care management and self-care.
  • Coaching patients to meet personal and clinical goals.
  • Scheduling provider appointments and accompanying patients when needed.
  • Reminding patients of upcoming appointments.
  • Helping patients access community and government-based services and resources.
  • Reinforcing education about symptom response plans.
  • Arranging transportation.
  • Closing gaps in care by reinforcing preventive monitoring and collaborating with practices to schedule diagnostic testing.
  • Assisting with access to educational videos.
• Support Nurse Practitioner (NP) and RNCM care team members by facilitating in-home telehealth visits.
• Use motivational interviewing techniques to encourage 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 of healthcare-related experience.
• Experience working with Medicare, Medicaid, and/or Special Needs populations.
• Experience working in a physician office.

Preferred Qualifications

• Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, or Community Health Worker experience.
• Exposure to renal patients.
• Bilingual in Spanish, Cantonese, or Mandarin, with fluency in clinical terminology.

Skills

• Demonstrated success working as part of a multi-disciplinary team, including communication with physicians and registered nurses.
• Effective written and verbal communication skills with cultural awareness.
• Computer proficiency in MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices, including multitasking across applications.
• Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility.
• Proven experience engaging patients in healthy behavior changes.
• Skills in navigating health systems and making necessary linkages to meet patient needs.
• Ability to consult with physicians and team members to ensure successful care plan implementation.
• Active participation in Care Management Coordination Committee (CMCC) meetings.
• Core values aligned with a patient-centered approach to care.
• Ability to adapt to a changing work environment 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 access to high-speed internet or leverage existing high-speed service.
• Access to a private, dedicated home workspace free from distractions to protect patient privacy (HIPAA compliance).
• Ability to travel throughout the assigned region for home, provider, or facility visits based on market needs.
• Ability to work the assigned schedule to meet client and patient needs.
• Ability to remain seated or standing for extended periods as required for essential job functions.

Proof of COVID-19 vaccination, annual Influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB are required for employment.

Our Commitment to Diversity

At Somatus, we celebrate what makes us unique—our people. We believe a culture built to foster and support diverse passions, experiences, and perspectives fuels 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.