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 delivers integrated care through a whole-person approach. 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 interdisciplinary care teams to improve outcomes and support patients in clinical, home, and facility settings.

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.
• 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 patients, nephrologists, PCPs, and the 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 licensed and non-licensed team members, delegating tasks as appropriate.
• Perform other duties as assigned.

Requirements

• RN license and ability to obtain licensure 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.
• Regular local travel is a key part of this role (75% of the time).

Preferred Qualifications

• BSN or higher level of education.
• Certified Case Manager (CCM).
• Field-based experience conducting home visits.
• 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 successful 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 strong data entry skills and use of MS Office (Word, Excel, PowerPoint, Outlook).
• Ability to type and talk simultaneously while navigating multiple applications.
• Adherence to departmental policies and procedures.

Benefits

• Subsidized personal healthcare coverage: Medical, Dental & Vision.
• 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 to protect patient privacy (HIPAA compliance).
• Ability to travel throughout the assigned region to conduct home, provider, or facility visits (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.

For this position, proof of COVID-19 vaccination, annual Influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB are required for employment.