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 facing multiple challenges, from accessing resources to adhering to treatment plans. This role is an important part of the interdisciplinary care team, responsible for outreach, scheduling face-to-face visits with members in their homes, dialysis clinics, and/or physician offices to support higher-risk members through barrier assessments and care plan education.

This is a physician practice partnership role involving meetings with members in clinical, home, and facility settings within designated locations. The RN Care Manager builds trusting relationships with nephrology practices and collaborates closely to improve patient outcomes.

Responsibilities

• Partner closely with physicians and practice staff to establish collaborative working 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 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 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.

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 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 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.

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 to empower 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 other team members to ensure that care plans are successfully implemented.
• 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 (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, including strong data entry skills, 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.
• 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.

Physical Requirements

• Access to a private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations.
• 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).
• Ability to work assigned schedule to meet patient and client expectations.
• Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions.

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.