Registered Nurse Care Manager, VBC

Somatus, Inc.•Springfield, OR

12d

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 accessing resources or following physician treatment plans. The role is part of an interdisciplinary care team and partners closely with patients, physician practices, and a Patient Health Advocate to build trust and improve outcomes. This physician-practice partnership role involves outreach and face-to-face visits with members in homes, dialysis clinics, physician offices, and other facilities within an assigned region. The RN Care Manager conducts assessments and care-plan education, coordinates care and transitions, identifies medical, behavioral, and social barriers, and collaborates with patients, nephrologists, primary care providers, and the interdisciplinary team to implement individualized care plans. The role also builds and maintains relationships with provider practices, supports collaborative workflows and care-team meetings, and provides clinical guidance to licensed and non-licensed team members. Regular local travel is a key part of the position, with travel throughout the assigned region for visits as needed up to 75% of the time. The position requires a private, dedicated home workspace and access to high-speed internet. Proof of COVID-19 vaccination and annual influenza vaccination, as well as immunizations for Hepatitis, MMR, Varicella, Tdap, and TB, is required for employment.

Requirements

RN license and ability to obtain licensure in other states as needed.
At least 2 years of RN experience, including work as part of a multidisciplinary team and with 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.
Comfort traveling to partner hospitals, clinics, and community-based facilities within the assigned region; regular local travel is a key part of the role.
Knowledge and experience empowering patients in self-management and shared decision-making.
Ability to work collaboratively with interdisciplinary team members and consult with physicians and others to support care-plan implementation.
Strong analytical, critical-thinking, community-engagement, and facilitation skills.
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.
Computer proficiency, including data entry, Microsoft Office (Word, Excel, PowerPoint, and Outlook), and telecom devices; ability to type and talk while navigating multiple applications.
Ability to adhere 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 travel throughout the assigned region for home, provider, or facility visits as needed, up to 75% of the time.
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 and annual influenza vaccination, plus 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 establish collaborative working relationships focused on improving patient outcomes, serving as Somatus’ primary representative within practices.
Support planning, coordination, and facilitation of regular interdisciplinary care-team meetings with partnered practices.
Build and maintain supportive relationships with patients and provider offices through in-person and telephone engagement.
Develop partnerships with provider practice teams to support clinical and operational goals and improve quality of care.
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 a continuum of quality care through in-person, telehealth, and telephone contact, including comprehensive assessments, transitional-care assessments, and reassessments.
Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning, and deliver care-coordination services.
Use nursing assessment skills to identify medical, behavioral, and social-determinant barriers affecting treatment plans.
Collaborate with patients, nephrologists, primary care providers, and the interdisciplinary care team to develop and implement individualized care plans.
Manage transitions of care by supporting effective handoffs and minimizing preventable readmissions.
Assess patients’ understanding 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.