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! The Central Nurse is a critical member of the care team working to complete comprehensive assessments, reassessments, and care coordination on attributed patients. This position will be working closely with chronic kidney disease (CKD), stages 3-5, and end stage renal disease (ESRD) patients, by phone or telehealth, to create a patient care plan. The primary focus of the assessment and care plan will be to improve patient outcomes by addressing risks associated with comorbid conditions and coordinating their care. Additional care coordination will be performed to focus on helping patients get permanent access, promoting home dialysis modalities and kidney transplantation, and educating patients on self-management. This is a fully remote role, applicable role licensure may be required. Responsibilities Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health. Assess a patient’s knowledge of their renal condition and provide education and self-management support. Based on the assessment, create, and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient— working in conjunction with the patient, patient’s Nephrologist, Primary Care Physician, and other members of the care team. Create and implement patient care plans, that are clearly documented, to manage and update with the patient. Provide additional support to manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions. Provide support to engage high risk members in the program by reviewing the patients chart and identifying ways Somatus can support the patient. Conduct outreach calls to unengaged patients, complete interdisciplinary care team meetings with special needs population. Provide clinical coordination to support team of Patient Health Advocates (PHAs), Social Workers, Renal Dieticians, and Pharmacists and to delegate tasks as appropriate. Coordinate care by serving as an 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. Provide ongoing reassessment and follow-up to improve patient outcomes.  Provide symptom management education using approved written guidelines as well as approved reference material provided by Somatus. Actively participate in new employee orientation, ongoing educational and compliance programs, staff meetings, continuous quality improvement, and performance/protocol evaluations and development. Maintain current nursing licensure by completing applications for renewal in a timely manner and by complying with all requirements for continuing education. Qualifications Required Current, unrestricted compact Registered Nurse (RN) license. 3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings. Able to work on multiple projects at once and juggling competing priorities. Highly organized and able to time manage effectively. Knowledge and experience to empower patients in self-management and shared decision making. Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients. Self-starter and critical thinking skills. Preferred Bachelor’s Degree in Nursing. Experience working with vulnerable patient population ESRD (End Stage Renal Disease), geriatrics, minorities, low income, uninsured, etc.) Competence using MS Office products, medical records, and telecom devices. Personal values consistent with a patient-centered approach to care that aligns with our company’s values: innovation, authenticity, tenacity, empowerment, and collaboration. 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.