Registered Nurse Care Manager, VBC

Somatus, Inc. • New Orleans, LA

6d

About The Position

The RN Care Manager, VBC focuses on high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, helping patients overcome barriers to resources and adherence to physician treatment plans. The role partners closely with patients, physician practices, and Somatus’s interdisciplinary care team to improve patient outcomes and care coordination.

This is a physician practice partnership role involving in-person visits with members in homes, dialysis clinics, facilities, and physician offices within an assigned region, as well as telehealth and telephone engagement. The RN Care Manager builds trusted relationships with practices, supports collaborative workflows and care planning, assesses medical, behavioral, and social barriers, and develops individualized care plans with patients and their care teams. The role also supports transitions of care, patient education and self-management, and provides clinical guidance and appropriate task delegation to team members.

The position requires regular local travel, which may be up to 75% of the time depending on market needs. The employee must have access to high-speed internet and a private, dedicated home workspace that protects patient privacy. Proof of COVID-19 vaccination and annual influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB, is required for employment.

Requirements

• Current RN license and ability to obtain licenses 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.
• Comfort with regular local travel to partner hospitals, clinics, and community-based facilities within the assigned region.
• 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 help ensure care plans are implemented successfully.
• Patient-centered approach consistent with the organization’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, MS Office (Word, Excel, PowerPoint, and Outlook), and telecom devices; ability to type and talk while 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 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 entering patients’ homes.
• Telephonic case management experience.

Responsibilities

• Partner with physicians and practice staff to build collaborative relationships focused on improving patient outcomes, serving as Somatus’s primary representative within the practice.
• Support planning, coordination, and facilitation of regular interdisciplinary care team meetings with partnered practices.
• Build 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 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 continuum-of-care support 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.
• Develop and implement individualized care plans with the patient, nephrologist, PCP, and interdisciplinary care team to address needs, remove barriers, and improve 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.

Benefits

• Subsidized medical, dental, and vision coverage.
• Wellness programs.
• Accrual of 3 weeks of vacation (PTO).
• CEU reimbursement.
• Tuition reimbursement.
• The position may be eligible for a discretionary performance-based bonus under the Company’s applicable incentive compensation plans.

What This Job Offers

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