Registered Nurse Care Manager, VBC

Somatus, Inc.•Portland, OR

12d

About The Position

The RN Care Manager, VBC serves high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, helping members access resources, adhere to treatment plans, and improve health outcomes. The role is part of an interdisciplinary care team and partners closely with patients, physicians, provider practices, and other care-team members. It includes building trusted relationships with nephrology practices and serving as Somatus’ primary representative within partnered practices. The position involves 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 clinical, behavioral, and social barriers, and works with patients, physicians, and the interdisciplinary team to develop and implement individualized care plans. The RN also supports care transitions, patient education and self-management, and collaboration between Somatus and provider practices. Regular local travel within the assigned region is a key part of the role and may be required up to 75% of the time. The work may be field-based or remote depending on member and client needs.

Requirements

Current 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.
Ability to reside in a location with high-speed internet access or access to existing high-speed internet service.
Ability to travel regularly within the assigned region to partner hospitals, clinics, community-based facilities, homes, provider offices, or facilities; travel may be required 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 for essential job functions.
Access to 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 and consult with physicians and other team members to support successful care-plan implementation.
Strong analytical, critical-thinking, community-engagement, and facilitation skills.
Patient-centered values and effective written and verbal communication demonstrating respect and cultural awareness.
Ability to adapt to a changing work environment based on member and client needs, including field-based or remote work.
Self-motivation and a strong work ethic.
Computer proficiency, including data entry, Microsoft Word, Excel, PowerPoint, and Outlook, and use of telecommunications 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 for employment.

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 build collaborative relationships focused on improved patient outcomes, serving as Somatus’ primary representative within the practice.
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 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 quality care through in-person, telehealth, and phone 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.
Work with patients, nephrologists, primary care physicians, and the interdisciplinary care team to develop and implement individualized care plans, address needs, remove barriers, and improve health outcomes.
Support effective handoffs and manage care transitions 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.