Registered Nurse Care Manager, VBC

About the role

Somatus is seeking an RN Care Manager, VBC to focus on high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations. This role partners closely with patients, physician practices, and an interdisciplinary care team to deliver outcomes-driven, integrated care through in-person, telehealth, and telephonic engagement. The RN Care Manager will conduct home, dialysis clinic, and physician office visits, perform barrier assessments, provide care plan education, and collaborate with nephrology practices to improve patient outcomes.

Responsibilities

• Conduct face-to-face visits with members in homes, dialysis clinics, and/or physician offices to support higher-risk patients through barrier assessments and care plan education.
• Develop and maintain trusting relationships with nephrology practices and serve as Somatus’ primary representative within those practices.
• Coordinate and facilitate 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 via in-person and telephonic engagement.
• 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 continuum of quality care through in-person, telehealth, or phone interactions, 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 treatment plans.
• In collaboration with the patient and care team, develop and implement individualized care plans to address needs, remove barriers, and improve health outcomes.
• Manage patients through transitions of care, 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 obtain licensure in other states as needed.
• 2+ years of RN experience, including working as part of a multidisciplinary 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 or the ability to leverage existing high-speed service.
• Willingness and ability to travel regularly to partner hospitals, clinics, and community-based facilities within the assigned region (approximately 75% of the time).

Preferred Qualifications

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

Knowledge, Skills, and Abilities

• 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 team members to ensure care plan implementation.
• 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.
• Computer proficiency, including data entry and MS Office (Word, Excel, PowerPoint, Outlook), and ability to multitask across applications.
• Adheres to departmental policies and procedures.

Physical Requirements

• Reside in a location with high-speed internet access or the ability to leverage existing high-speed service.
• Access to a private, dedicated home workspace free from distractions and compliant with HIPAA and privacy regulations.
• Ability to travel throughout the assigned region for 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 seated or standing positions for extended periods as required.

Somatus requires proof of COVID-19 vaccination, annual Influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB for employment.