Nurse Navigator

Overview

As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home.

It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you?

• Authenticity: We believe in real dialogue. In any interaction, with patients, partners, vendors, or our teammates, we are true to who we are, say what we mean, and mean what we say.
• Collaboration: We appreciate what every person at Somatus brings to the table and believe that together we can do and achieve more.
• Empowerment: We make sure every voice gets heard and all ideas are considered, especially when it comes to our patients' lives or our partners' best interests.
• Innovation: We relentlessly look for ways to improve upon the status quo to continuously deliver new solutions.
• Tenacity: We see challenges as opportunities for growth and improvement - especially when new solutions will make a difference for our patients and partners.

• Subsidized, personal healthcare coverage (medical, dental vision)
• Accrual of 3 weeks' Vacation (PTO)
• Professional Development, CEU, and Tuition Reimbursement
• Curated Wellness Benefits supporting teammates physical and mental well-being
• Community engagement opportunities
• And more!

The Nurse Navigator is a critical member of the Somatus care team, serving both as a patient advocate and a strategic partner to case management teams and hospital staff. This role collaborates with local leadership and case management teams at key facilities identified by the Operations Manager to strengthen relationships, improve care coordination, and expand awareness of Somatus program benefits.

Focused on high-needs populations-including those with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The Nurse Navigator works with hospital staff, patients, and caregivers to address barriers to safe discharge, access to resources, and adherence to treatment plans. The Nurse Navigator provides education and program information to hospital staff to increase engagement and awareness of Somatus services.

As a central point of contact, the Nurse Navigator plays an essential role in early identification of readmission risks and supports members and families in navigating complex healthcare systems. This includes care delivered in the hospital and post-acute care facilities. The Nurse Navigator is also directly responsible for completing post-discharge Transitions of Care (TOC) assessment to ensure safe, timely, and coordinated movement.

Following these transitions, The Nurse Navigator ensures a warm and effective handoff of the patient to the Population Health team to support ongoing engagement, care coordination, and long-term disease management.

• Identify members admitted to assigned hospitals using census reporting and Health Information Exchange (HIE) & collaborate with Case Managers on appropriate discharge needs of those members.
• 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;
• Nurse Navigator will make contact and engage members, establish positive, supportive relationships with members as first point of contact.
• Introduce new eligible hospitalized members to the program, educate on benefits, and obtain verbal consent to the program.
• 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.
• Align with post-acute facilities and collaborate on appropriate discharge needs of members as needed.
• Work with care team members to address social determinants of members health that may impact treatment and assist with identifying community resources to address needs.
• Collaborate with Transition of Care Team to identify needs and/or barriers.
• Identify discharge dates and assist with setting Transitions of Care program expectation.
• Coordinate post discharge support and follow up for the member which may include a post-discharge home visit. Collaborate with RNCM in the field to identify members with frequent admissions and develop ongoing conversations and plans to address areas to reduce admissions and cost utilization.
• Schedule to…