Nurse Navigator

Somatus•Fairfax, VA

33d

About The Position

As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home. It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you? Showing Up Somatus Strong We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: Authenticity: We believe in real dialogue. In any interaction, with patients, partners, vendors, or our teammates, we are true to who we are, say what we mean, and mean what we say. Collaboration: We appreciate what every person at Somatus brings to the table and believe that together we can do and achieve more. Empowerment: We make sure every voice gets heard and all ideas are considered, especially when it comes to our patients' lives or our partners' best interests. Innovation: We relentlessly look for ways to improve upon the status quo to continuously deliver new solutions. Tenacity: We see challenges as opportunities for growth and improvement - especially when new solutions will make a difference for our patients and partners. Showing Up for You We offer more than 25 Health, Growth, and Wealth Work Perks to help teammates learn, grow, and be the best version of themselves, including: Subsidized, personal healthcare coverage (medical, dental vision) Accrual of 3 weeks' Vacation (PTO) Professional Development, CEU, and Tuition Reimbursement Curated Wellness Benefits supporting teammates physical and mental well-being Community engagement opportunities And more! The Nurse Navigator is a critical member of the Somatus care team, serving both as a patient advocate and a strategic partner to case management teams and hospital staff. This role collaborates with local leadership and case management teams at key facilities identified by the Operations Manager to strengthen relationships, improve care coordination, and expand awareness of Somatus program benefits. Focused on high-needs populations-including those with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The Nurse Navigator works with hospital staff, patients, and caregivers to address barriers to safe discharge, access to resources, and adherence to treatment plans. The Nurse Navigator provides education and program information to hospital staff to increase engagement and awareness of Somatus services. As a central point of contact, the Nurse Navigator plays an essential role in early identification of readmission risks and supports members and families in navigating complex healthcare systems. This includes care delivered in the hospital and post-acute care facilities. The Nurse Navigator is also directly responsible for completing post-discharge Transitions of Care (TOC) assessment to ensure safe, timely, and coordinated movement. Following these transitions, The Nurse Navigator ensures a warm and effective handoff of the patient to the Population Health team to support ongoing engagement, care coordination, and long-term disease management.

Requirements

Active RN license from Virginia or compact state.
Familiar with Medicare, Medicaid or Special Needs population.
Experience withdischarge planning process.
3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings.
3-5 years experience with EMR (Electronic Medical Records) systems.
Minimum three (3) years working with patients with chronic and/or behavioral health needs.
Ability to be credentialed in local hospital system.
Ability to anticipate outcomes and mitigate risks and potential barriers to readmission
Three (3) years demonstrated success in working as part of a multi-disciplinary team to include working with Physicians.
Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
Establish and nurture positive working relationships with hospital team and Somatus field care teams.
Familiar with local community resources.
Able to multi-task, highly organized and able to manage time effectively.
Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
Ability to travel throughout the assigned region and comfortable with conducting home and facility visits (over 75% same day travel) depending on assigned market.
Demonstrates empathy, enthusiasm, a deep sense of humor, and a strong work ethic.
Experience collaborating with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.)
Ability to establish rapport with patient and family by inquiring and listening.
Familiar with electronic medical records
Competence using MS Office products and telecom devices.
Core values consistent with a patient-centered approach to care
Proactively acts as a patient advocate and responds with resolve.
Knowledge and experience to empower patients in self-management and shared decision making.
Strong analytical and critical thinking skills.

Responsibilities

Identify members admitted to assigned hospitals using census reporting and Health Information Exchange (HIE) & collaborate with Case Managers on appropriate discharge needs of those members.
Conduct Transition of Care assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health;
Nurse Navigator will make contact and engage members, establish positive, supportive relationships with members as first point of contact
Introduce new eligible hospitalized members to the program, educate on benefits, and obtain verbal consent to the program.
Create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient.
Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s).
Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility.
Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
Assess the patient's knowledge of their discharge care requirements and renal condition and provide education and self-management support.
Align with post-acute facilities and collaborate on appropriate discharge needs of members as needed
Work with care team members to address social determinants of members health that may impact treatment and assist with identifying community resources to address needs.
Collaborate with Transition of Care Team to identify needs and/or barriers.
Identify discharge dates and assist with setting Transitions of Care program expectation
Coordinate post discharge support and follow up for the member which may include a post-discharge home visit. · Collaborate with RNCM in the field to identify members with frequent admissions and develop ongoing conversations and plans to address areas to reduce admissions and cost utilization.
Schedule to complete transitional care assessments on discharged members within 7 days to ensure safe transitions from hospital to home and prevent avoidable readmissions.
Other duties as assigned.