Patient Health Advocate- VBC

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 #Somatus Strong 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.

We offer 25+ health, growth, and wealth work packets 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

The Patient Health Advocate (PHA) role supports Somatus 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 PHA for VBC will work closely with Somatus patients and physician practices, including spending time working from within physician offices and will be the first and primary representative of Somatus, responsible for establishing trust and building relationships with the partnered physician s and practices.

• Works under the guidance of practice physicians and/or a nurse care manager.
• Partners closely with physicians and practice office staff to build a positive, collaborative relationship focused on working together to improve care for patients, support clinical and operational goals, and improves Somatus’ primary representative in the practice.
• Supports the preparation and management of the regular integrated, interdisciplinary care team meetings each month.
• Serve as primary contact for provider practice regarding patient needs and care coordination.
• Follow‑up with health management plans and goals in coordination with the RNCM.
• Collaborates with the provider practice to build and fine‑tune workflows to support operational goals with the RNCM and care team.
• Educate the provider practice about the Somatus program, reinforcing collaborative workflows.
• Function as an advocate for the patient and support the patients throughout their journeys.
• Conduct patient outreach (i.e., telephonic and in‑person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients.
• Conduct outreach to members currently or recently in the inpatient setting to engage in the Somatus program and/or connect with a Transitions of Care RN to complete an assessment.
• Assist patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Assist members in scheduling appointments for follow‑up post‑discharge from the inpatient setting with their provider.
• Schedule members for initial and subsequent Somatus assessments with the RNCM.
• Use the care coordination platform to document all activities in collaboration with physician practices.
• Engages with patients who need assistance with self‑care needs, such as:
  • Address language and cultural barriers to care management and self‑care.
  • Coach and guide the patient to meet both personal and clinical goals.
  • Schedules provider appointments on behalf of their patients.
  • Accompanies patients to their appointments when needed.
  • Reminds patients of their upcoming appointments.
• Helps patients access community and government‑based services and resources.
• Helps to reinforce education provided to the patient and/or caregiver about symptom response plans.
• Arranges transportation.
• Facilitates closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule /…