Registered Nurse Care Manager, VBC

Company Overview

Somatus is a leading provider of outcomes‑driven care for individuals and communities living with chronic conditions. Through a whole‑person approach, Somatus delivers integrated care for patients with cardio, kidney, metabolic, or other chronic conditions, partnering with health plans, health systems, and provider groups. The company values culture, intentional leadership, and clinical excellence.

Role Overview

The RN Care Manager, Value‑Based Care (VBC) focuses on high‑needs Chronic Kidney Disease (CKD) and End‑Stage Kidney Disease (ESKD) populations. Working closely with patients, physician practices, and the Patient Health Advocate, the RN Care Manager serves as a key member of the interdisciplinary care team, providing outreach, scheduling face‑to‑face visits, barrier assessments, and care‑plan education.

Responsibilities

• Partner closely with physicians and practice staff to establish collaborative relationships focused on improving patient outcomes.
• Serve as Somatus’ primary representative within partnered practices 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 and improve 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 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 the treatment plan.
• Develop and implement individualized care plans in collaboration with patients, nephrologists, primary‑care providers, and the interdisciplinary team.
• Manage patients through transitions of care, supporting effective handoffs and minimizing preventable readmissions.
• Assess patients’ knowledge of discharge care requirements and renal condition; provide 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.
• Perform other duties as assigned.

Qualifications

• RN license with ability to obtain licensure in other states as needed.
• 2+ years of RN experience, including work as part of a multidisciplinary team and collaboration with physicians.
• Valid BLS certification from a licensed AHA or American Red Cross training facility.
• Renal, Chronic Kidney Disease, or dialysis care experience as a primary focus of your work.
• Residence in a location with high‑speed internet access (or ability to leverage existing high‑speed service).
• Comfortable traveling to partner hospitals, clinics, and community‑based facilities within the assigned region; regular local travel is a key part of the role.
• Commitment to reasonable accommodations in accordance with the ADA.

Preferred Qualifications

• BSN or higher level of education.
• Certified Case Manager (CCM) credential.
• Field‑based experience conducting home visits.
• Telephonic case‑management experience.

Knowledge, Skills, and Abilities

• Ability to empower patients in self‑management and shared decision‑making.
• Strong collaboration skills with interdisciplinary team members.
• Analytical and critical‑thinking abilities.
• Community engagement and facilitation skills.
• Consultation skills to ensure successful implementation of care plans.
• Active participation in Care Management Coordination Committee (CMCC) meetings.
• Core values aligned with a patient‑centered approach to care.
• Adaptability to changing work environments (field‑based or remote).
• Self‑motivation and strong work ethic.
• Effective written and verbal communication with cultural awareness.
• Computer proficiency, including data entry and MS Office (Word, Excel, PowerPoint, Outlook) and ability to multitask on telecom devices.
• Adherence to departmental policies and procedures.

Physical Requirements

• Residence in a location with high‑speed internet and a private, distraction‑free home workspace to protect patient privacy (HIPAA).
• Ability to travel throughout the assigned region for home, provider, or facility visits, up to 75% of the time.
• Ability to work the assigned schedule to meet patient and client expectations.
• Ability to remain seated or standing for extended periods as required to perform essential job functions.