The RN Care 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 working closely with complex renal patients in their home, dialysis center, by phone and electronically as needed. The primary focus will be to improve patient outcomes by helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating their care. ?
Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; The RN Care Manager is expected to conduct approximately 12 assessments per week and manage a panel of about 150 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 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 dietitians, and delegate tasks as appropriate.
MEASURES OF SUCCESS:
Dialysis Interventions monitoring and coordination.
3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings.
Core values consistent with a patient-centered approach to care.
Proactively acts as a patient advocate and responds with resolve.
Knowledge and experience to empower patients in self-management and shared decision making.
Enjoys working collaboratively with team members.
Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
Strong analytical and critical thinking skills. Strong community engagement and facilitation skills.
Ability to travel throughout the assigned region and comfort with conducting home visits (up to 50% same day travel).
Bachelor’s Degree in Nursing.
Demonstrates empathy, enthusiasm, a great sense of humor, and a strong work ethic.
Experience working 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 records.
Community Outreach experience, preferred.
Competence using MS Office products and telecom devices.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. 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.
Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law.? Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics.? Discrimination of any type will not be tolerated.
Outcomes-based partnerships that move the needle on cost and quality. We understand the unique complexities involved in managing and treating kidney disease and help break down silos and barriers impacting care.Field-based nursing and interdisciplinary teams working to significantly reduce dialysis and non-dialysis costs, manage CKD, slow disease progression, address social determinants of health and improve patient health outcomes.