Registered Nurse Care Manager, VBC

How We’ll Support You

We offer 25+ health, growth, and wealth work perks to help teammates be the best version of themselves, including:

• Subsidized personal healthcare coverage: Medical, Dental & Vision, plus Wellness programs
• Paid Time Off: Accrual of 3 weeks’ Vacation (PTO)
• Professional development: CEU and tuition reimbursement

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.

Responsibilities

Work closely with Somatus patients and physician practices, working closely with the Patient Health Advocate to establish trust with physicians and practices.

• Work with the interdisciplinary care team to 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.
• 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.

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 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

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.

Benefits

This position may be eligible for a discretionary performance-based bonus in accordance with the Company's applicable incentive compensation plans.

Pay

$80,000 to $90,000 per year

Schedule

75% of the time, this position requires regular local travel to conduct home, provider, or facility visits, depending on the assigned market needs.