RN Care Manager, Field

How You'll Make an Impact:

The RN Care Manager, Field (RN) is a leading member of the care team consisting of nurses, dietitians, pharmacists, social workers, patient health advocates, and physicians. Somatus operates in a hybrid telehealth model that blends remote work with in-person visits to member's homes, healthcare providers, and clinical facilities to meet patient needs. This position will working closely with complex renal patients in their home, dialysis center, by phone, and electronically as needed. The primary focus of the RN will be to improve patient outcomes by educating members on their condition and formulating a care management plan, which includes helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating care.

• Conduct assessments virtually or in-person that include the medical, behavioral, pharmaceutical, and social needs of the patient, while identifying gaps in care and barriers to good health.

• Create and implement a care plan, in conjunction with the patient, and other members of the care team, that addresses identified needs, removes barriers to care, and improves the health of the patient.

• Ability to establish trusting relationships with members & caregivers and identify innovative strategies to improve and maintain engagement.

• Use protocols and pathways in line with established disease management and care management programs to optimize clinical outcomes.

• Facilitate care across the continuum of care, spanning various settings such as the home, hospital, skilled nursing facility, and acute care facility.

• Manage patients with transitions of care to minimize avoidable readmissions.

• Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s).

• Document pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate.

• Meet role performance and quality goal metrics

• Perform care management activities as required in operational workflows

How You'll Strengthen Our Team:

Qualifications:

• 2+ years of healthcare-related experience
• Active unrestricted RN license in current state of residence with the ability to qualify for additional state licenses
• Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility as needed

Preferred:

• Bilingual Languages in either Spanish, Cantonese, or Mandarin with the ability to converse fluently in a clinical setting using clinical terms.
• Nursing experience in a renal specialty.
• Field-based experience conducting home visits with patients.
• Nursing experience in case management or care management, preferably coordinating care across multiple settings.

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 the care plan is successfully implemented.
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings.
• 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 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.

Physical Requirements

• Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet service.

• Access to a private dedicated home workspace free from distractions and to protect patient privacy regarding HIPAA and Privacy regulations.

• Ability to travel throughout the assigned region to conduct home, provider, or facility visits, depending on the assigned market needs. All work-related travel is eligible for mileage reimbursement and travel expense coverage in accordance with company policy.

• Ability to work assigned schedule to meet patient and client expectations.

• Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions.

Compensation:

$78,000 to $97,000 per year

We offer competitive compensation that reflects market conditions and recognizes the skills, experience, and contributions of our team members. Compensation for the role will depend on a number of factors, including a candidate's qualifications, skills, competencies, experience, and geographic location and may fall outside of the range shown above.

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Our priority is the health and safety of our members, colleagues, partners, and community. For this position, we require proof of COVID-19 vaccination, annual Influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB for employment.