Patient Health Advocate- VBC

How We’ll Support You

• 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 adapting 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 physicians and practices.

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

• 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.
• Educates the provider practice about the Somatus program, reinforcing collaborative workflows.
• Functions as an advocate for the patient and supports the patient throughout their journeys.
• Conducts patient outreach (i.e., telephonic and in-person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients.
• Conducts 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.
• Assists patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Assists members in scheduling appointments for follow-up post-discharge from the inpatient setting with their provider.
• Schedules members for initial and subsequent Somatus assessments with the RNCM.
• Uses 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:
• Addresses language and cultural barriers to care management and self‑care.
• Coaches and guides 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 / complete diagnostic testing.
• Assists patients with access to educational videos.
• Supports NP and RNCM care team members by facilitating in‑home telehealth visits with patients.
• Utilizes motivational interviewing techniques to encourage patients to make behavioral changes.

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

• Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to Renal patients.
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