Registered Nurse Care Manager, VBC

About the Role

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.

Responsibilities

• 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.

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.

Preferred Qualifications

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

Knowledge, Skills, and Abilities

• 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.

Physical Requirements

• Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service.
• Access to 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.

Pay

$80,000 to $90,000 per year