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? Showing Up Somatus Strong We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: 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. Showing Up for You We offer more than 25 Health, Growth, and Wealth Work Perks to help teammates learn, grow, and be the best version of themselves, including: 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! This position is responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing basic nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. This is a fully remote role where compact licensure is strongly preferred. **The schedule for this position includes some evening hours where you will be expected to work until approximately 8pm, based on member availability. For example: 11am-8pm OR a split shift 8am-12pm and then 4pm-8pm** Responsibilities Consistently exhibits behavior and communication skills that demonstrate our company's commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Prioritizes patient care needs upon initial visit and addresses emerging issues. Meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan. Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings. Consults with physician and other team members to ensure that care plan is successfully implemented. Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs and approved by medical management in order to optimize clinical outcomes. Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management. Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care. Works in coordination with the care team and demonstrates accountability with patient management and outcome. Discusses Durable Power of Attorney (DPoA) and advanced directive status with PCP when applicable. Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families. Provides accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues. Participates actively in assigned Care Management Coordination Committee (CMCC) meetings. Documents pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate. Coordinates care with central departments on assigned patient caseload, including out-of-area, inpatient central and transplant. Adheres to departmental policies and procedures as approved by Office of the Medical Director (OMD) Quality Committee. Qualifications Education: Graduation from an accredited school of Nursing. Compact RN license. Bachelor’s degree in Nursing preferred. Experience: Bilingual in Spanish, Mandarian, Cantonese Fully conversational in English & Spanish or English & Mandarin or English & Cantonese Minimum: Over 3 years and up to and including 5 years of experience in clinical setting demonstrating the ability to assess, document and implement the nursing care plan Minimum: Past clinical experience. Preferred: 3 to 5 years of acute nursing experience in critical care. Preferred: Previous care management, utilization review or discharge planning experience. Preferred: HMO experience. Knowledge, Skills, and Abilities: Assesses and interprets customer needs and requirements. Identifies solutions to non-standard requests and problems. Solves moderately complex problems and/or conducts moderately complex analyses. Works with minimal guidance; seeks guidance on only the most complex tasks. Translates concepts into practice Other Duties 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. Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely-held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law. 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.