Patient Health Advocate- VBC

Somatus, Inc.•Jacksonville, FL

12d•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 address barriers to resources and adherence to physician treatment plans. The PHA works closely with patients and physician practices, including spending time in physician offices, and serves as Somatus’ primary representative in partnered practices. The role builds trust and collaborative relationships with physicians and practice staff to support patient care and clinical and operational goals. The position works under the guidance of practice physicians and/or a nurse care manager and partners with the RN care manager (RNCM) and interdisciplinary care team. Somatus describes the work environment as hybrid telehealth, with a combination of remote work and visits to members’ homes. The PHA coordinates patient outreach and care transitions, helps patients access services and meet personal and clinical goals, supports practice workflows, and documents activities in a care coordination platform. The role requires a high school diploma or equivalent, relevant healthcare and care- or case-management experience, and the ability to travel throughout the assigned region as needed. Proof of COVID-19 vaccination and specified additional immunizations is required for employment.

Requirements

High school diploma or equivalent.
At least 1 year of experience in case management or care management; experience coordinating care across multiple settings is preferred.
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 and communicate and collaborate with physicians and registered nurses.
Effective written and verbal communication skills, including respectful and culturally aware interactions with patients and clients.
Computer proficiency with Microsoft 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 healthy behavior changes.
Ability to navigate health systems and establish linkages to meet specific needs.
Ability to consult with physicians and other team members to support successful care-plan implementation.
Patient-centered core values, self-motivation, and a strong work ethic.
Ability to work the assigned schedule to meet client and patient needs.
Reside where high-speed internet is available or be able to leverage existing high-speed internet service.
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 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 for employment.

Nice To Haves

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

Responsibilities

Partner with physicians and practice staff to establish collaborative relationships that support patient care and clinical and operational goals.
Support preparation and management of regular 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 the provider practice, RNCM, and care team to develop and refine workflows that support operational goals.
Educate provider practices about the Somatus program and reinforce collaborative workflows.
Advocate for patients and support them throughout their care journeys.
Conduct telephonic and in-person outreach to introduce patients to the Somatus program, encourage enrollment, and promote engagement.
Contact members who are currently or recently hospitalized 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 facilitate effective transitions and minimize avoidable readmissions.
Help members schedule provider follow-up appointments after inpatient discharge.
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 for patients, accompany them when needed, and remind them of upcoming appointments.
Help patients access community and government services and resources, and arrange transportation.
Reinforce education for patients and caregivers about symptom response plans and preventive monitoring.
Collaborate with physician practices to close care gaps and schedule or complete diagnostic testing.
Help patients access 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.
Adhere to departmental policies and procedures and adapt to changing work environments based on member and client needs.