Patient Health Advocate- VBC

About the role

Somatus is a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, and we are seeking a Patient Health Advocate to support our high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations.

The Patient Health Advocate will work closely with Somatus patients and physician practices, establishing trust and building relationships with partnered physicians and practices, and will be the first and primary representative of Somatus.

Responsibilities

• Support the preparation and management of regular integrated, interdisciplinary care team meetings
• 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
• Educate the provider practice about the Somatus program, reinforcing collaborative workflows
• Function as an advocate for the patient and support the patients throughout their journeys
• Conduct patient outreach to introduce and align patients to the Somatus program, encourage enrollment, and engage patients
• Assist patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions
• 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 addressing 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 and accompany patients to their appointments when needed
• Remind patients of their upcoming appointments and help patients access community and government-based services and resources
• Help reinforce education provided to the patient and/or caregiver about symptom response plans and 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 and 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 include Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to Renal patients, and bilingual ability in Spanish, Cantonese, or Mandarin.

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 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 and navigating the health systems and making necessary linkages to meet specific needs

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
• 25+ health, growth, and wealth work perks to help teammates be the best version of themselves