Registered Nurse Care Manager, VBC

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, collaborating 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, 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.

How You'll Strengthen Our Team:

Qualifications:

• RN license and ability to get licensed in other states as needed
• 2+ years of RN experience, including working as part of a multi‑disciplinary team of physicians
• Valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider
• Renal, Chronic Kidney Disease or Dialysis Care experience as a main focus of your job
• Reside in a location that can receive a high‑speed internet connection or can leverage existing high‑speed internet service
• Comfortable traveling to…