Patient Health Advocate- VBC

Somatus, Inc. • Mobile, AL

1d • Hybrid

About The Position

The Patient Health Advocate (PHA) supports Somatus patients with high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD), helping them access resources and follow their physicians’ treatment plans. The PHA works closely with patients and physician practices, including working from within physician offices, and serves as Somatus’ primary representative to partnered practices. The role builds trust and collaborative relationships with physicians and practice staff to improve patient care and support clinical and operational goals. The PHA works under the guidance of practice physicians and/or a nurse care manager and supports integrated, interdisciplinary care team meetings and coordination of patient care.

The position uses a hybrid telehealth model that combines remote work with visits to members’ homes and travel to provider offices or facilities as needed. The PHA conducts patient outreach by phone and in person, supports program enrollment and engagement, assists with transitions of care and follow-up appointments, and documents activities in the care coordination platform. The role also helps patients address self-care needs, overcome language and cultural barriers, access community resources and transportation, understand educational materials, and make behavioral changes. The PHA supports nurse practitioners and registered nurse care managers by facilitating in-home telehealth visits.

Employment requires proof of COVID-19 vaccination and annual influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB. Somatus states that reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

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 on a multidisciplinary team and communicate and collaborate with physicians and registered nurses.
• Effective written and verbal communication skills, with respect and cultural awareness in interactions with patients and clients.
• Computer proficiency with Microsoft Office (Word, Excel, PowerPoint, and Outlook), and telecom devices; ability to type and talk simultaneously 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 making healthy behavior changes.
• Ability to navigate health systems and make linkages to meet specific needs.
• Ability to consult with physicians and other team members to support successful implementation of care plans.
• Patient-centered approach to care, adaptability to changing work environments, self-motivation, strong work ethic, and adherence to departmental policies and procedures.
• Reside somewhere with access to high-speed internet and have a private, dedicated home workspace that protects patient privacy and complies with HIPAA and privacy regulations.
• Ability to travel throughout the assigned region for home, provider, or facility visits according to 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 for essential job functions.
• Proof of COVID-19 vaccination, annual influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB.

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 ability to converse in a clinical setting using clinical terms.

Responsibilities

• Build positive, collaborative relationships with physicians and practice office staff to improve patient care and support clinical and operational goals.
• Serve as the primary contact for provider practices regarding patient needs and care coordination.
• Support preparation and management of monthly integrated, interdisciplinary care team meetings.
• Follow up on health management plans and goals in coordination with the RN care manager (RNCM).
• Collaborate with provider practices, the RNCM, and the care team to develop and refine workflows; educate practices about the Somatus program and 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 support engagement.
• Reach out to members who are currently or recently inpatient to engage them in the Somatus program and/or connect them with a Transitions of Care RN for assessment.
• Assist patients during transitions of care to support effective transitions and minimize avoidable readmissions.
• Help members schedule post-discharge follow-up appointments with providers and 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 that affect care management and self-care.
• Coach and guide patients toward personal and clinical goals and use motivational interviewing to encourage behavioral change.
• Schedule provider appointments, accompany patients to appointments when needed, and remind patients of upcoming appointments.
• Help patients access community and government services and resources, arrange transportation, and access educational videos.
• Reinforce education about symptom response plans and preventive monitoring, and collaborate with physician practices to close care gaps and schedule or complete diagnostic testing.
• Support nurse practitioners and RNCM care team members by facilitating in-home telehealth visits.
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings and adhere to departmental policies and procedures.

Benefits

• Subsidized medical, dental, and vision coverage.
• Wellness programs.
• Paid time off, with initial standard accrual beginning at three weeks of vacation (PTO); internal transfers retain a higher historical tenure tier where applicable.
• CEU and tuition reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED