Registered Nurse Care Manager, VBC

About the role

Somatus is a leading outcomes-driven care provider for individuals and communities living with chronic conditions. As an RN Care Manager, VBC, you will focus on high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, collaborating with patients, physician practices, and interdisciplinary teams to improve health outcomes through integrated care and barrier removal.

Responsibilities

• Conduct outreach and schedule face-to-face visits with members in homes, dialysis clinics, and/or physician offices to support higher-risk members through barrier assessments and care plan education.
• Develop trusting relationships with nephrology practices and collaborate to improve patient outcomes.
• Partner closely with physicians and practice staff to establish collaborative working relationships focused on improving patient outcomes.
• Serve as Somatus’ primary representative within partnered practices and build trusted relationships over time.
• Support care team planning, coordination, and facilitation of 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 clinical and operational goals and improve overall quality of patient care.
• 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 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 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, delegating tasks as appropriate.

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 prior roles.
• Reside in a location with high-speed internet access.
• 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 required.

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.
• 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 care plans are 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, including strong data entry and use of MS Office (Word, Excel, PowerPoint, Outlook), and telecom devices; ability to type and talk simultaneously while navigating multiple applications.
• Adheres to departmental policies and procedures.

Physical Requirements

• Reside in a location with high-speed internet access.
• Access to a private, dedicated home workspace free from distractions and capable of protecting patient privacy under HIPAA and Privacy regulations.
• Ability to travel throughout the assigned region to conduct home, provider, or facility visits as needed, approximately 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 to perform essential job functions.