Registered Nurse Care Manager, VBC

Somatus, Inc.•Fayetteville, NC

About The Position

The RN Care Manager, VBC supports high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations facing challenges such as accessing resources and adhering to physician treatment plans. This physician-practice partnership role works closely with patients, physician practices, and interdisciplinary care teams to improve outcomes. The nurse serves as Somatus’ primary representative within partnered practices, building trusted relationships with physicians and practice staff and supporting collaborative clinical and operational workflows. The role includes outreach and in-person visits with members in their homes, dialysis clinics, facilities, and physician offices, as well as telephonic and telehealth engagement. The RN conducts assessments and reassessments, identifies medical, behavioral, and social barriers to care, and collaborates with patients, nephrologists, primary care providers, and the interdisciplinary team to develop and implement individualized care plans. The RN also supports transitions of care, patient education, and self-management, and provides clinical guidance and oversight to licensed and non-licensed team members. The position requires regular local travel throughout the assigned region, which may account for 75% of the time. The employee must be able to work the assigned schedule, have access to high-speed internet and a private, dedicated home workspace, and meet the physical requirements of extended seated or standing work. Proof of COVID-19 vaccination and annual influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB, is required for employment.

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, or ability to leverage existing high-speed internet service.
Comfort with regular local travel to partner hospitals, clinics, and community-based facilities within the assigned region.
Ability to work the assigned schedule to meet patient and client expectations.
Ability to travel throughout the assigned region for home, provider, or facility visits as needed, up to 75% of the time.
Ability to remain seated or standing for extended periods as required to perform essential job functions.
Ability to use a private, dedicated home workspace free from distractions and suitable for protecting patient privacy under HIPAA and privacy regulations.
Knowledge and experience empowering patients in self-management and shared decision-making.
Ability to work collaboratively with interdisciplinary team members.
Strong analytical, critical-thinking, community-engagement, and facilitation skills.
Ability to consult with physicians and other team members to ensure care plans are implemented successfully.
Patient-centered approach consistent with the company’s core values.
Ability to adapt to changing work environments based on member and 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 when interacting with patients and clients.
Computer proficiency, including data entry, MS Office (Word, Excel, PowerPoint, and Outlook), and telecom devices; ability to type and talk simultaneously while navigating multiple applications.
Adherence to departmental policies and procedures.
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 conducting home visits.
Telephonic case management experience.

Responsibilities

Partner with physicians and practice staff to establish collaborative relationships focused on improving patient outcomes; serve as Somatus’ primary representative within the practice.
Support planning, coordination, and facilitation of regular interdisciplinary care team meetings with partnered practices for complex, high-priority patients.
Build and maintain 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 care through in-person, telehealth, and telephone communication, 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.
Collaborate with patients, nephrologists, primary care providers, and the interdisciplinary care team to develop and implement individualized care plans, remove barriers, and improve health outcomes.
Support transitions of care through effective handoffs and efforts to minimize 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.