Registered Nurse Care Manager

Somatus • Wausau, WI

80d

About The Position

As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home. It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you? We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: Authenticity, Collaboration, Empowerment, Innovation, and Tenacity. The RN Care Manager is a critical member of the care team consisting of nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position will be working closely with complex renal patients in their home, dialysis center, by phone and electronically as needed. The primary focus will be to improve patient outcomes by helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating their care.

Requirements

• 1+ years of nursing experience in case management or care management, preferably coordinating care across multiple settings.
• 2+ years healthcare related experience.
• Current, unrestricted compact Registered Nurse license.
• Requires all teammates to maintain current, valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.
• Core values consistent with a patient-centered approach to care.
• Proactively acts as a patient advocate and responds with resolve.
• Knowledge and experience to empower patients in self-management and shared decision making.
• Enjoys working collaboratively with team members.
• Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
• Strong analytical and critical thinking skills.
• Strong community engagement and facilitation skills.

Nice To Haves

• Bachelor's degree in nursing.
• Demonstrates empathy, enthusiasm, a great sense of humor, and a strong work ethic.
• Experience working with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.).
• Ability to establish rapport with patient and family by inquiring and listening.
• Familiar with electronic medical records.
• Community Outreach experience preferred.
• Competence using MS Office products and telecom devices.

Responsibilities

• Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; The RN Care Manager is expected to conduct approximately 12 assessments per week and manage a panel of about 150 assessed patients.
• Based on this assessment, and in conjunction with the patient, patient's nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient.
• Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s).
• Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility.
• Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Assess the patient's knowledge of their renal condition and provide education and self-management support.
• Provide ongoing reassessment and follow-up to improve patient outcomes.
• Provide clinical oversight to non-licensed support team of community health workers and health coaches and licensed support team of social workers and renal dietitians, and delegate tasks as appropriate.

Benefits

• Subsidized, personal healthcare coverage (medical, dental vision).
• Accrual of 3 weeks' Vacation (PTO).
• Professional Development, CEU, and Tuition Reimbursement.
• Curated Wellness Benefits supporting teammates physical and mental well-being.
• Community engagement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree