Registered Nurse Care Manager, VBC

About Somatus

Somatus is a leading provider of outcomes‑driven care for individuals and communities living with chronic conditions. We help patients enjoy More Healthy Days at Home™.

We take a whole‑person approach, delivering integrated care for patients with cardiovascular, kidney, metabolic, or other chronic conditions. We partner closely with health plans, systems, and provider groups to support patients at risk of developing these conditions.

We hire talent driven by purpose and impact. Since our founding in 2016, we have grown rapidly, with a culture that values clinical excellence and intentional leadership.

• Subsidized personal healthcare coverage
  :
  Medical, Dental & Vision, plus Wellness programs
• Paid Time Off
  : 3 weeks’ Vacation (PTO)
• Professional development
  : CEU and tuition reimbursement

• Partner closely with physicians and practice staff to establish collaborative relationships focused on improving patient outcomes.
• Serve as Somatus’s primary representative within the practice and build trusted relationships over time.
• Support care team planning, coordination, and facilitation of regular interdisciplinary care team meetings with partnered practices.
• 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 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, and deliver care coordination services.
• Utilize nursing assessment skills to identify medical, behavioral, and social determinants of health barriers affecting the treatment plan.
• In collaboration with the patient, nephrologist, PCP, and interdisciplinary care team, develop and implement individualized care plans to address identified needs, remove barriers to care, and improve overall health outcomes.
• Manage patients through transitions of care by supporting effective handoffs and minimizing preventable readmissions.
• Assess the patient’s knowledge of their discharge care requirements and renal condition and provide education and self‑management support.
• Provide clinical guidance and oversight to both non‑licensed (community health workers, health coaches) and licensed (social workers, renal dietitians) team members, delegating tasks as appropriate.
• Perform other duties as assigned.

• RN license and ability to obtain licensure in other states as needed.
• Minimum 2 years of RN experience, including working as part of a multidisciplinary team and with physicians.
• Valid BLS certification from an AHA or American Red Cross training facility.
• Experience in renal, chronic kidney disease, or dialysis care as a main focus of job.
• Reside in a location with high‑speed internet connectivity.
• Comfortable traveling to partner hospitals, clinics, and community facilities within your region; regular local travel is a key part of this role.

• BSN or higher education.
• Certified Case Manager (CCM).
• Field‑based experience going into homes.
• Telephonic case management experience.

• Knowledge and experience to empower patients in self‑management and shared decision‑making.
• Work collaboratively with interdisciplinary team members.
• Strong analytical and critical thinking skills; strong community engagement and facilitation skills.
• Ability to consult with physicians and other team members to ensure the care plan is successfully implemented.
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings.
• Core values consistent…