RN Care Manager- Transitions of Care

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 #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.

Does this sound like you? Keep reading.

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

The RN Transition of Care RN 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 collaborating closely with complex renal patients in their home, facility, by phone and electronically as needed. The primary focus will be to improve the movement of a patient from one care setting to another (hospital, skilled care, rehab, or long term care).

• Conduct Transition of Care assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; the RN TOC Manager is expected to conduct approximately 12‑15 assessments per week and manage a panel of about (70) seventy 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 discharge care requirements and 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 dieticians, and delegate tasks as appropriate.
• Other duties as assigned.

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications:

• Bachelor’s degree in nursing preferred.
• 3‑5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings.
• Current, unrestricted compact Registered Nurse license.
• Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider.

Knowledge, Skills, and Abilities:

• Demonstrates empathy, enthusiasm, a deep sense of humor, and a strong work ethic.
• Experience collaborating 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…