Patient Health Advocate- VBC

About Somatus

Somatus is a leading provider of outcomes‑driven care for individuals and communities living with chronic conditions, helping patients across the country enjoy More Healthy Days at Home™.

We offer 25+ health, growth, and wealth work perks to help teammates be the best version of themselves, including subsidized personal healthcare coverage, paid time off, professional development, and more.

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 works closely with Somatus patients and physician practices, working from within physician offices and serving as the first and primary representative of Somatus, responsible for establishing trust and building relationships with partnered physicians and practices.

Somatus offers a hybrid telehealth environment with a combination of remote days and visits to members’ homes.

• Work under the guidance of practice physicians and/or a nurse care manager.
• Partner closely with physicians and practice office staff to build a positive, collaborative relationship focused on improving care for patients and supporting clinical and operational goals.
• Support the preparation and management of the regular integrated interdisciplinary care team meetings each month.
• Serve as primary contact for provider practices regarding patient needs and care coordination.
• Follow‑up with health management plans and goals in coordination with the RNCM.
• Collaborate with provider practices to build and fine‑tune workflows to support operational goals with the RNCM and care team.
• Educate provider practices about the Somatus program, reinforcing collaborative workflows.
• Function as an advocate for patients and support them throughout their journeys.
• Conduct patient outreach (telephone 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.
• Engage with patients who need assistance with self‑care needs, including:
• Addressing language and cultural barriers to care management and self‑care.
• Coaching and guiding patients to meet personal and clinical goals.
• Scheduling provider appointments on behalf of patients.
• Accompanying patients to appointments when needed.
• Reminding patients of upcoming appointments.
• Help patients access community and government‑based services and resources.
• Help reinforce education provided to the patient and/or caregiver about symptom response plans.
• Arrange transportation.
• Facilitate closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule/complete diagnostic testing.
• Assist patients with access to educational videos.
• Support NP and RNCM care team members by facilitating in‑home telehealth visits with patients.
• Utilize motivational interviewing techniques to encourage patients to make behavioral changes.

• High school diploma or equivalent required.
• 1+ year experience in case management or care management, preferably coordinating care across multiple settings.
• 2+ years of healthcare‑related experience.
• Experience working with Medicaid, Medicare, and/or Special Needs populations.
• Experience working in a physician office.

• Background as a Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker, or exposure to renal patients.
• Bilin…