Registered Nurse Care Manager, VBC

Somatus, Inc. • Miami, FL

2d

About The Position

The RN Care Manager, VBC supports high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations who may face barriers to resources and adherence to physician treatment plans. The role works closely with patients, physician practices, Patient Health Advocates, and an interdisciplinary care team to build trusted partnerships and improve patient outcomes.

This physician-practice partnership role involves outreach and face-to-face visits with members in their homes, dialysis clinics, physician offices, and other facilities within an assigned region. The RN provides assessments, care-plan education, care coordination, and ongoing engagement in person, by telehealth, and by phone. The nurse also partners with provider practices to improve collaboration, workflows, and the quality of patient care.

The RN Care Manager identifies medical, behavioral, and social barriers; develops individualized care plans with patients, providers, and the care team; supports transitions of care; and provides education and self-management support. The role also provides clinical guidance and oversight to licensed and non-licensed team members, delegating tasks as appropriate. Regular local travel is a key component, with travel potentially required up to 75% of the time. The position requires a private, dedicated home workspace and access to high-speed internet. Compensation is $80,000 to $90,000 per year, and the position may be eligible for a discretionary performance-based bonus.

Requirements

• Active RN license and ability to obtain licensure in other states as needed.
• At least 2 years of RN experience, including work with a multidisciplinary team and physicians.
• Valid BLS certification from a licensed American Heart Association or American Red Cross training facility or provider.
• Renal, Chronic Kidney Disease, or Dialysis Care experience as a main focus of the job.
• Residence in a location with access to high-speed internet service.
• Ability and comfort traveling regularly within the assigned region to partner hospitals, clinics, community-based facilities, homes, provider offices, and other facilities; travel may be required up to 75% of the time.
• Knowledge and experience empowering patients in self-management and shared decision-making.
• Ability to work collaboratively with interdisciplinary team members.
• Strong analytical and critical-thinking skills, as well as community engagement and facilitation skills.
• Ability to consult with physicians and other team members to ensure successful implementation of care plans.
• Patient-centered approach consistent with the company’s core values.
• Ability to adapt to changing work environments and member or client needs, including field-based or remote work.
• Self-motivation and a strong work ethic.
• Effective written and verbal communication demonstrating respect and cultural awareness in interactions with patients and clients.
• Computer proficiency, including data entry and MS Office (Word, Excel, PowerPoint, and Outlook), and ability to use telecommunications devices while typing and navigating multiple applications.
• Adherence to departmental policies and procedures.
• Access to a private, dedicated home workspace free from distractions and suitable for protecting patient privacy under HIPAA and privacy regulations.
• Ability to work the assigned schedule to meet patient and client expectations.
• 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.

Nice To Haves

• BSN or higher level of education.
• Certified Case Manager (CCM).
• Field-based experience visiting patients in their homes.
• Telephonic case management experience.

Responsibilities

• Partner with physicians and practice staff to build collaborative working relationships focused on improving patient outcomes, serving as Somatus’ primary representative within the practice.
• Support planning, coordination, and facilitation of regular interdisciplinary care team meetings with partner practices.
• Build supportive relationships with patients and provider offices through in-person and telephonic engagement.
• Develop partnerships with provider practice teams to support clinical and operational goals and improve patient care quality.
• Collaborate with provider practices to develop and optimize workflows aligned with operational objectives and care team processes.
• Educate provider practices about the Somatus program and reinforce collaborative, integrated workflows.
• Provide continuity of quality care through in-person, telehealth, and telephone engagement, including comprehensive assessments, transitional care assessments, and reassessments.
• Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning, and provide care coordination.
• Use nursing assessment skills to identify medical, behavioral, and social determinants of health barriers affecting treatment plans.
• Develop and implement individualized care plans with patients, nephrologists, primary care providers, and the interdisciplinary care team to address needs, remove barriers, and improve health outcomes.
• Support transitions of care through effective handoffs and efforts to minimize preventable readmissions.
• Assess patients’ knowledge of discharge care requirements and renal conditions, and provide education and self-management support.
• Provide clinical guidance and oversight to licensed and non-licensed team members, delegating tasks as appropriate.
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings.
• Perform other duties as assigned.

Benefits

• Medical, dental, and vision coverage, including subsidized personal healthcare coverage.
• Wellness programs.
• Paid time off, with initial standard vacation accrual beginning at 3 weeks; internal transfers retain a higher historical tenure tier where applicable.
• CEU and tuition reimbursement.
• The position may be eligible for a discretionary performance-based bonus, subject to the company’s applicable incentive compensation plans.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed