Patient Health Advocate - Practice Lead

Somatus, Inc.•Asheville, NC

14d

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! This position will be focused 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. The Patient Health Advocate – Practice Lead will work closely with Somatus patients and physician practices, including spending time working from within physician offices. The Patient Health Advocate – Practice Lead will be the first and primary representative of Somatus to partnered physician practices. He/she will be the key team member to establish trust with physicians and practices and will be responsible for building this relationship. The Patient Health Advocate – Practice Lead will work as an extension of Somatus’ clinical care team, specifically under the guidance of a renal nurse care manager. The individual taking this role will manage his/her caseload through in-person, telephonic and electronic means of communications and coordination. This position is a market-based position.

Requirements

High school diploma or equivalent.
Experience working with Medicare, Medicaid, or Special Needs populations.
Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker experience.
Ability to connect with people and understand the challenges they face.
Ability to use a range of outreach methods to engage individuals and groups in diverse settings.
Well connected to the community and exceptional understanding of the resources available to their patient population.
Strong written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients and in physician offices.
Experience working in a high-volume environment.
Initiative-taker – able to prioritize and drive to completion,
Ability to travel throughout the assigned region and comfort with conducting home visits (50-75% same day travel).
Ability to establish rapport with patients, families, and physician offices,
Outgoing personality with ability to speak clearly and with confidence to patients and providers in a variety of settings,
Ability to adapt to change quickly.
Ability to work within a demanding environment.

Nice To Haves

Experience working in a physician office.
Experience collaborating with patients with chronic and behavioral health needs.
Demonstrated success in working as part of a multi-disciplinary team including communicating and collaborating with Physicians and Registered Nurses.
Proven experience with engaging patients in making healthy behavior changes.
Proven skills in navigating the health systems and making necessary linkages to meet specific needs.
Can speak other language(s).
Experience working with Electronic Medical Record systems and other documentation platforms.

Responsibilities

Works under the guidance of practice physicians and/or a nurse care manager.
Partners closely with physicians and practice office staff to build a collaborative relationship focused on working together to improve care for patients. Built relationships over time as Somatus’ primary representative in the practice.
Helps the care team prepare and manage the regular integrated, interdisciplinary care team meetings each month.
Serve as primary contact for provider practice regarding patient needs and care coordination.
Follow-up with health management plans and goals in coordination with the RNCM.
Establish positive, supportive relationships with patients and physician offices and provides feedback through in-person and telephonic interactions.
Builds relationships with the provider practice team to support clinical and operational goals and help improve patient care.
Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.
Educate the provider practice about the Somatus program, reinforcing collaborative workflows.
Function as an advocate for the patient and support the patients throughout their journeys.
Conduct outreach (i.e., telephonic and in-person) to patients to introduce the Somatus program, encourage enrollment and engage patients.
Conduct an initial outreach query and discussion to help align patients with the most appropriate program in accordance with program guidelines.
Schedule members for initial and subsequent Somatus assessments with the RNCM
Documents their activities in the care coordination platform, including care plan activities conducted.
Engages with patients who need assistance with self-care needs in addition to what a nurse care manager can provide via phone, such as:
Address language and cultural barriers to care management and self-care.
Coach and guide the patient to meet both personal and clinical goals.
Schedules provider appointments on behalf of their patients.
Accompanies patients to their appointments when needed.
Reminds patients of their upcoming appointments.
Helps patients access community and government-based services and resources.
Helps to reinforce education provided to the patient and/or caregiver about symptom response plans.
Arranges transportation.
Facilitates closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule / complete diagnostic testing.
Assists patients with access to educational videos.
Support NP and RNCM care team members by facilitating in-home telehealth visits with patients.
Utilize motivational interviewing techniques to encourage patients to make behavioral changes.