Patient Health Advocate- VBC

Somatus, Inc.•Villas, FL

12d•Hybrid

About The Position

The Patient Health Advocate (PHA) supports Somatus’s high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, helping patients address barriers to accessing resources and following physician treatment plans. The PHA works closely with patients and physician practices, including from within physician offices, and serves as Somatus’s primary representative to build trust and relationships with partnered physicians and practices. The position works under the guidance of practice physicians and/or a nurse care manager and operates in a hybrid telehealth environment, combining remote work with visits to members’ homes and other assigned locations. The PHA coordinates patient outreach, care transitions, appointments, resources, and follow-up in collaboration with physician practices, registered nurses, nurse care managers, and the broader care team. The role also supports practice workflows, interdisciplinary care team meetings, patient education, and patient engagement in self-care and healthy behavior changes.

Requirements

High school diploma or equivalent.
At least 1 year of experience in case management or care management, preferably coordinating care across multiple settings.
At least 2 years of healthcare-related experience.
Experience working with Medicare, Medicaid, and/or Special Needs populations.
Experience working in a physician office.
Demonstrated ability to work as part of a multidisciplinary team, including communicating and working with physicians and registered nurses.
Effective written and verbal communication skills, with respect and cultural awareness when interacting with patients and clients.
Computer proficiency with MS Office (Word, Excel, PowerPoint, and Outlook) and telecommunications devices, including the ability to type and talk while navigating multiple applications.
Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility as needed.
Experience engaging patients in healthy behavior changes.
Skills in navigating health systems and making linkages to meet specific needs.
Ability to consult with physicians and other team members to support successful implementation of care plans.
Patient-centered core values.
Ability to adapt to a changing work environment based on member and client needs.
Ability to adhere to departmental policies and procedures.
Self-motivation and a strong work ethic.
Reside in a location with access to high-speed internet.
Have access to a private, dedicated home workspace free from distractions to protect patient privacy and comply with HIPAA and privacy regulations.
Ability to travel throughout the assigned region for home, provider, or facility visits based on market needs.
Ability to work the assigned schedule to meet client and patient needs.
Ability to remain seated or standing for extended periods as required to perform essential job functions.
Proof of COVID-19 vaccination, annual influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB are required for employment.

Nice To Haves

Experience as a Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, or Community Health Worker, or exposure to renal patients.
Fluency in Spanish, Cantonese, or Mandarin, including the ability to converse in a clinical setting using clinical terms.

Responsibilities

Build positive, collaborative relationships with physicians and practice office staff to support patient care and clinical and operational goals.
Support preparation and management of monthly integrated, interdisciplinary care team meetings.
Serve as the primary contact for provider practices regarding patient needs and care coordination.
Follow up on health management plans and goals in coordination with the RNCM.
Collaborate with provider practices, the RNCM, and the care team to develop and refine workflows.
Educate provider practices about the Somatus program and reinforce collaborative workflows.
Advocate for patients and support them throughout their care journeys.
Conduct telephone and in-person outreach to introduce patients to the Somatus program, encourage enrollment, and promote engagement.
Contact members who are currently or recently inpatient to engage them in the program and/or connect them with a Transitions of Care RN for an assessment.
Assist patients during care transitions to support effective transitions and minimize avoidable readmissions.
Help members schedule post-discharge follow-up appointments with their providers.
Schedule initial and subsequent Somatus assessments with the RNCM.
Document activities in the care coordination platform in collaboration with physician practices.
Address language and cultural barriers to care management and self-care.
Coach and guide patients toward personal and clinical goals.
Schedule provider appointments on behalf of patients, remind patients about upcoming appointments, and accompany patients to appointments when needed.
Help patients access community and government-based services and resources.
Reinforce education for patients and caregivers about symptom response plans.
Arrange transportation for patients.
Help close gaps in care by reinforcing preventive monitoring education and collaborating with practices to schedule or complete diagnostic testing.
Assist patients in accessing educational videos.
Support NP and RNCM team members by facilitating in-home telehealth visits with patients.
Use motivational interviewing techniques to encourage behavioral changes.
Participate actively in assigned Care Management Coordination Committee (CMCC) meetings.