Registered Nurse Care Manager, VBC
Somatus · Indianapolis, IN · 1 mo ago
HealthcareFull-time
We need to output HTML fragment with sections: Use for headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections with real specific content. The posting includes description about company, but not a specific "About the role" heading; we can create "About the role" with description of role? The posting includes "How We’ll Support You:" with benefits list. Also "Qualifications:" and "Preferred Qualifications:" and "Knowledge, Skills, and Abilities:" and "Physical Requirements". Also mention travel etc. No explicit Pay or Schedule. So we should not create Pay or Schedule sections. Benefits: they list "25+ health, growth, and wealth work perks" with specific items: 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. So we can create Benefits section with those items.
Responsibilities: many bullet points describing duties. We'll create Responsibilities section with
for headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections with real specific content. The posting includes description about company, but not a specific "About the role" heading; we can create "About the role" with description of role? The posting includes "How We’ll Support You:" with benefits list. Also "Qualifications:" and "Preferred Qualifications:" and "Knowledge, Skills, and Abilities:" and "Physical Requirements". Also mention travel etc. No explicit Pay or Schedule. So we should not create Pay or Schedule sections. Benefits: they list "25+ health, growth, and wealth work perks" with specific items: 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. So we can create Benefits section with those items.
Responsibilities: many bullet points describing duties. We'll create Responsibilities section with - .
Requirements: maybe combine Qualifications and Preferred? The instruction: Use headings for Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide what goes where. Likely "Qualifications" for required qualifications, "Preferred Qualifications" maybe also under Qualifications? Could split: Qualifications (required) and Skills (knowledge, skills, abilities). Requirements maybe include license, experience, BLS, renal experience, internet, travel. We'll put those under Requirements. Qualifications maybe include BSN or higher, CCM, field-based experience, telephonic case management. Skills: Knowledge, Skills, and Abilities list.
We must not repeat job title as heading. No Job ID.
We must remove boilerplate: EEO, legal, etc. The posting includes some statements like "Somatus is committed to providing reasonable accommodations..." that's okay to keep? It's not boilerplate? It's about accommodations, could be considered legal but it's part of job description. Probably keep.
Also "This job description is not designed to cover..." that's boilerplate; remove. Also "Reasonable accommodations may be made..." similar; maybe keep? It's repetitive. Might remove as boilerplate. Also "Our priority is the health and safety..." that's boilerplate; remove. Also vaccination requirements: that's specific content, keep.
We need to preserve all substantive information; not invent.
Let's extract sections.
First, introductory paragraph about Somatus: could be considered "About the role"? Actually it's about company. Could be placed under "About the role" maybe. But instruction: use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can include About the role with description of Somatus and role purpose. That seems appropriate.
Let's craft About the role: combine first paragraphs: "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. We hire the brightest and boldest — talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn’t just a milestone — it’s a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence. Does this sound like you? Keep reading." That's substantive.
Now Responsibilities: list duties from "The RN Care Manager, VBC focuses..." through "Perform other duties as assigned." We'll extract bullet points.
Let's list them:
- The RN Care Manager, VBC focuses on 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 RN Care Manager will work closely with Somatus patients and physician practices, working closely with the Patient Health Advocate to establish trust with physicians and practices.
- The RN Care Manager, VBC is an important part of the interdisciplinary care team.
- They are responsible for outreach, scheduling face-to-face visits with members in their homes, dialysis clinics, and/or physician offices to support higher-risk members who need barrier assessments, and face-to-face care plan education.
- In addition, our field nurses develop trusting relationships with the nephrology practices in their markets and work closely with those practices to support increased collaboration to improve patient outcomes.
- This is a physician practice partnership role that involves meeting with members in clinical, home, and facility settings, within their designated locations.
- Partner closely with physicians and practice staff to establish a collaborative working relationship focused on improving patient outcomes.
- Serve as Somatus’ primary representative within the practice and build trusted relationships over time.
- Support the care team in planning, coordinating, and facilitating regular interdisciplinary care team meetings with partnered practices to improve outcomes for complex, high-priority patients.
- Establish and maintain positive, supportive relationships with patients and provider offices through in-person and telephonic engagement.
- Develop strong partnerships with provider practice teams to support both clinical and operational goals and improve the overall quality of patient care.
- Collaborate with provider practices to develop and optimize workflows that align with operational objectives and care team processes.
- Educate provider practices on the Somatus program and reinforce collaborative, integrated workflows.
- Provide a complete continuum of quality care through close communication with members via in-person, telehealth or on-phone interaction, including comprehensive assessments, transitional care assessments and reassessments.
- Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning, and deliver care coordination services.
- Utilize nursing assessment skills to identify medical, behavioral, and social determinants of health barriers affecting the treatment plan.
- In collaboration with the patient, nephrologist, PCP, and interdisciplinary care team, develop and implement individualized care plans to address identified needs, remove barriers to care, and improve overall health outcomes.
- Manage patients through transitions of care by supporting effective handoffs and minimizing preventable readmissions.
- Assess the patient’s knowledge of their discharge care requirements and renal condition and provide education and self-management support.
- Provide clinical guidance and oversight to both non-licensed (community health workers, health coaches) and licensed (social workers, renal dietitians) team members, delegating tasks as appropriate.
- Perform other duties as assigned.
Now Requirements: from "Qualifications:" list required qualifications.
- RN license and ability to get licensed in other states as needed
- 2+ years of RN experience, including working as part of a multi-disciplinary team and Physicians.
- Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
- Renal, Chronic Kidney Disease or Dialysis Care experience as a main focus of your job
- Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service
- Comfortable traveling to partner hospitals, clinics, and community-based facilities within your assigned region to support care coordination, build relationships, and collaborate with clinical teams.
- Regular local travel is a key part of this role.
- Somatus is committed to providing reasonable accommodations, in accordance with the ADA, to support all team members in performing the essential functions of their role. (maybe keep)
- 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.
Also maybe "Access to private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations." That's under Physical Requirements but could be requirement. We'll maybe put under Requirements as well.
But we have separate Physical Requirements heading? Not in allowed headings list. Could include under Requirements or Skills? Probably under Requirements.
We'll include physical requirements as part of Requirements.
Now Qualifications (preferred): list:
- BSN or higher level of education
- Certified Case Manager (CCM)
- Field-based experience going into homes
- Telephonic case management experience
Now Skills: Knowledge, Skills, and Abilities list:
- Knowledge and experience to empower patients in self-management and shared decision-making.
- Work collaboratively with interdisciplinary team members.
- Strong analytical and critical thinking skills.
- Strong community engagement and facilitation skills.
- 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 a changing work environment based on member and client needs (field-based or remote work).
- Self-motivated with a strong work ethic.
- Effective written and verbal communication skills that demonstrate respect and cultural awareness during interactions with patients and clients
- Computer proficiency, to include strong data entry, 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
- Adheres to departmental policies and procedures.
Now Benefits: list:
- 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
- (maybe also "25+ health, growth, and wealth work perks" but we already captured specifics.)
Now we should not include Pay or Schedule sections.
Now produce HTML fragment with headings and - for lists,
for prose.
We need to ensure we don't repeat job title as heading. Not needed.
We'll output:
About the role
...
Responsibilities
- ...
...
Requirements
- ...
...
Qualifications
- ...
...
Skills
- ...
...
Benefits
- ...
...
Make sure to preserve all info, no extra.
Check for any duplicated lines: we have "Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service" appears twice (in Qualifications and Physical Requirements). We'll include once under Requirements.
Also "Access to private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations." appears under Physical Requirements; we should include that as a requirement.
Also "Ability to travel throughout the assigned region to conduct home, provider, or facility visits, depending on the assigned market needs, as needed 75% of the time." and "Ability to work assigned schedule to meet patient and client expectations." and "Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions." These are physical requirements; include under Requirements.
Also "Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions." include.
Now ensure we didn't miss any substantive info: The line "Somatus is committed to providing reasonable accommodations, in accordance with the ADA, to support all team members in performing the essential functions of their role." appears twice; include once.
Also "Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions." maybe duplicate; we can keep one.
Also "Our priority is the health and safety of our members, colleagues, partners, and community." we decided to remove as boilerplate.
Also "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
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can include About the role with description of Somatus and role purpose. That seems appropriate.
Let's craft About the role: combine first paragraphs: "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. We hire the brightest and boldest — talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn’t just a milestone — it’s a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence. Does this sound like you? Keep reading." That's substantive.
Now Responsibilities: list duties from "The RN Care Manager, VBC focuses..." through "Perform other duties as assigned." We'll extract bullet points.
Let's list them:
- The RN Care Manager, VBC focuses on 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 RN Care Manager will work closely with Somatus patients and physician practices, working closely with the Patient Health Advocate to establish trust with physicians and practices.
- The RN Care Manager, VBC is an important part of the interdisciplinary care team.
- They are responsible for outreach, scheduling face-to-face visits with members in their homes, dialysis clinics, and/or physician offices to support higher-risk members who need barrier assessments, and face-to-face care plan education.
- In addition, our field nurses develop trusting relationships with the nephrology practices in their markets and work closely with those practices to support increased collaboration to improve patient outcomes.
- This is a physician practice partnership role that involves meeting with members in clinical, home, and facility settings, within their designated locations.
- Partner closely with physicians and practice staff to establish a collaborative working relationship focused on improving patient outcomes.
- Serve as Somatus’ primary representative within the practice and build trusted relationships over time.
- Support the care team in planning, coordinating, and facilitating regular interdisciplinary care team meetings with partnered practices to improve outcomes for complex, high-priority patients.
- Establish and maintain positive, supportive relationships with patients and provider offices through in-person and telephonic engagement.
- Develop strong partnerships with provider practice teams to support both clinical and operational goals and improve the overall quality of patient care.
- Collaborate with provider practices to develop and optimize workflows that align with operational objectives and care team processes.
- Educate provider practices on the Somatus program and reinforce collaborative, integrated workflows.
- Provide a complete continuum of quality care through close communication with members via in-person, telehealth or on-phone interaction, including comprehensive assessments, transitional care assessments and reassessments.
- Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning, and deliver care coordination services.
- Utilize nursing assessment skills to identify medical, behavioral, and social determinants of health barriers affecting the treatment plan.
- In collaboration with the patient, nephrologist, PCP, and interdisciplinary care team, develop and implement individualized care plans to address identified needs, remove barriers to care, and improve overall health outcomes.
- Manage patients through transitions of care by supporting effective handoffs and minimizing preventable readmissions.
- Assess the patient’s knowledge of their discharge care requirements and renal condition and provide education and self-management support.
- Provide clinical guidance and oversight to both non-licensed (community health workers, health coaches) and licensed (social workers, renal dietitians) team members, delegating tasks as appropriate.
- Perform other duties as assigned.
Now Requirements: from "Qualifications:" list required qualifications.
- RN license and ability to get licensed in other states as needed
- 2+ years of RN experience, including working as part of a multi-disciplinary team and Physicians.
- Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
- Renal, Chronic Kidney Disease or Dialysis Care experience as a main focus of your job
- Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service
- Comfortable traveling to partner hospitals, clinics, and community-based facilities within your assigned region to support care coordination, build relationships, and collaborate with clinical teams.
- Regular local travel is a key part of this role.
- Somatus is committed to providing reasonable accommodations, in accordance with the ADA, to support all team members in performing the essential functions of their role. (maybe keep)
- 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.
Also maybe "Access to private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations." That's under Physical Requirements but could be requirement. We'll maybe put under Requirements as well.
But we have separate Physical Requirements heading? Not in allowed headings list. Could include under Requirements or Skills? Probably under Requirements.
We'll include physical requirements as part of Requirements.
Now Qualifications (preferred): list:
- BSN or higher level of education
- Certified Case Manager (CCM)
- Field-based experience going into homes
- Telephonic case management experience
Now Skills: Knowledge, Skills, and Abilities list:
- Knowledge and experience to empower patients in self-management and shared decision-making.
- Work collaboratively with interdisciplinary team members.
- Strong analytical and critical thinking skills.
- Strong community engagement and facilitation skills.
- 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 a changing work environment based on member and client needs (field-based or remote work).
- Self-motivated with a strong work ethic.
- Effective written and verbal communication skills that demonstrate respect and cultural awareness during interactions with patients and clients
- Computer proficiency, to include strong data entry, 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
- Adheres to departmental policies and procedures.
Now Benefits: list:
- 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
- (maybe also "25+ health, growth, and wealth work perks" but we already captured specifics.)
Now we should not include Pay or Schedule sections.
Now produce HTML fragment with headings and - for lists,
for prose.
We need to ensure we don't repeat job title as heading. Not needed.
We'll output:
About the role
...
Responsibilities
- ...
...
Requirements
- ...
...
Qualifications
- ...
...
Skills
- ...
...
Benefits
- ...
...
Make sure to preserve all info, no extra.
Check for any duplicated lines: we have "Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service" appears twice (in Qualifications and Physical Requirements). We'll include once under Requirements.
Also "Access to private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations." appears under Physical Requirements; we should include that as a requirement.
Also "Ability to travel throughout the assigned region to conduct home, provider, or facility visits, depending on the assigned market needs, as needed 75% of the time." and "Ability to work assigned schedule to meet patient and client expectations." and "Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions." These are physical requirements; include under Requirements.
Also "Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions." include.
Now ensure we didn't miss any substantive info: The line "Somatus is committed to providing reasonable accommodations, in accordance with the ADA, to support all team members in performing the essential functions of their role." appears twice; include once.
Also "Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions." maybe duplicate; we can keep one.
Also "Our priority is the health and safety of our members, colleagues, partners, and community." we decided to remove as boilerplate.
Also "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
- for lists,
for prose. We need to ensure we don't repeat job title as heading. Not needed. We'll output:
About the role
...
Responsibilities
- ... ...
Requirements
- ... ...
Qualifications
- ... ...
Skills
- ... ...
Benefits
- ... ...