Registered Nurse Care Manager, VBC

Job description

How We Show Up for Our Patients: As a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus is helping patients across the country enjoy More Healthy Days at Home. Care at Somatus goes beyond treatment. Through a whole-person approach, we deliver outcomes-driven integrated care and show up #SomatusStrong for our patients and teammates. We partner closely with health plans, health systems, and provider groups to support patients with, or at risk of developing, cardio, kidney, metabolic, or other chronic conditions. We hire the brightest and boldest - talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn't just a milestone - it's a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence. Does this sound like you? Keep reading. How We'll Support You: We offer 25+ health, growth, and wealth work perks to help teammates be the best version of themselves, including: Subsidized personal healthcare coverage : Medical, Dental & Vision, plus Wellness programs Paid Time Off : Accrual of 3 weeks' Vacation (PTO) Professional development : CEU and tuition reimbursement How You'll Make an Impact: The RN Care Manager, VBC focuses on high?needs?Chronic Kidney Disease?(CKD) and End-Stage Kidney Disease (ESKD) populations that face multiple challenges, from accessing resources to adhering to a physician's treatment plan. The RN Care Manager will work closely with Somatus patients and physician practices, working closely with the Patient Health Advocate to?establish?trust with physicians and practices.? The RN Care Manager, VBC is an important part of the interdisciplinary care team.? They?are responsible for?outreach, scheduling face-to-face visits with members in their homes, dialysis clinics,?and/or?physician offices to support higher-risk members who need barrier assessments, and face-to-face care plan education.? In addition, our field nurses develop trusting relationships with the nephrology practices in their markets and work closely with those practices to support increased collaboration to improve patient outcomes.?? This is a physician practice partnership role that involves meeting with members in clinical, home, and facility settings, within their designated locations. Partner closely with physicians and practice staff to establish a collaborative working relationship focused on improving patient outcomes. Serve as Somatus' primary representative within the practice and build trusted relationships over time. Support the care team in planning, coordinating, and facilitating regular interdisciplinary care team meetings with partnered practices to improve outcomes for complex, high-priority patients. Establish and maintain positive, supportive relationships with patients and provider offices through in-person and telephonic engagement. Develop strong partnerships with provider practice teams to support both clinical and operational goals and improve the overall quality of patient care. Collaborate with provider practices to develop and optimize workflows that align with operational objectives and care team processes. Educate provider practices on the Somatus program and reinforce collaborative, integrated workflows. Provide a complete continuum of quality care through close communication with members via in-person, telehealth or on-phone interaction,?including comprehensive assessments, transitional care assessments and reassessments. ? ? Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning,...