Registered Nurse Care Manager, VBC

About the Role

As a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus helps patients enjoy More Healthy Days at Home™. The RN Care Manager, VBC focuses on high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, working closely with patients, physician practices, and the Patient Health Advocate to establish trust and improve outcomes. This role is a key part of the interdisciplinary care team, responsible for outreach, face-to-face visits, and care plan education in homes, dialysis clinics, and physician offices.

Responsibilities

• Partner closely with physicians and practice staff to establish collaborative relationships 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.
• 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 clinical and operational goals and improve patient care quality.
• Collaborate with provider practices to develop and optimize workflows aligned 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 in-person, telehealth, or phone interactions, including comprehensive assessments and transitional care.
• 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 treatment plans.
• Develop and implement individualized care plans in collaboration with the patient, nephrologist, PCP, and interdisciplinary care team.
• Manage patients through transitions of care by supporting effective handoffs and minimizing preventable readmissions.
• Assess patient knowledge of discharge care requirements and renal condition, providing education and self-management support.
• Provide clinical guidance and oversight to non-licensed (community health workers, health coaches) and licensed (social workers, renal dietitians) team members.
• Perform other duties as assigned.

Requirements

• 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 with physicians.
• Valid BLS certification 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 with access to high-speed internet.
• Comfortable traveling to partner hospitals, clinics, and community-based facilities within your assigned region.

Preferred Qualifications

• BSN or higher level of education.
• Certified Case Manager (CCM).
• Field-based experience going into homes.
• Telephonic case management experience.

Skills

• Knowledge and experience empowering patients in self-management and shared decision-making.
• Ability to work collaboratively with interdisciplinary team members.
• Strong analytical and critical thinking skills.
• Strong community engagement and facilitation skills.
• Ability to consult with physicians and team members to ensure care plan implementation.
• Active participation 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.
• Self-motivated with a strong work ethic.
• Effective written and verbal communication skills demonstrating respect and cultural awareness.
• Computer proficiency, including MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices.
• Adherence to departmental policies and procedures.

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.

Pay

$80,000 to $90,000 per year. Compensation reflects market conditions and recognizes skills, experience, and contributions. The final offer may vary based on qualifications, skills, competencies, experience, and geographic location. This position may also be eligible for a discretionary performance-based bonus.

Schedule

• Regular local travel is a key part of this role (75% of the time).
• Ability to work assigned schedule to meet patient and client expectations.
• Ability to remain in a seated or standing position for extended periods as required.

Physical Requirements

• Access to a private, dedicated home workspace free from distractions to protect patient privacy (HIPAA compliance).
• Ability to travel throughout the assigned region to conduct home, provider, or facility visits.