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Population Health Nurse Practitioner
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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 As a Population Health Nurse Practitioner at Somatus you will guide the clinical operations and strategies of our care team, collaborating with our Somatus and Community providers and broader market team to ensure the delivery of patient outcomes through the Somatus model of care. While this role is not heavily patient facing, the Nurse Practitioner will ensure the delivery of high-quality patient care, efficient medical management, and effective utilization of healthcare resources, delivered by providing clinical support and guidance to our Registered Nurse Care Manager and Population Health Field Teams. The Nurse Practitioner is responsible for providing medical expertise, clinical oversight, and strategic direction to enable success improving the health engagement and management of a population. The position will work in partnership with our field-based nurses, patient health advocates, and physicians and assist in delivering premium care management to every patient. Duties may also include patient health assessment and annual wellness exams in the patient homes, dialysis center and telehealth. In this capacity the position will establish strategies to improve or manage a patient’s health and introduce habits for health promotion. Responsibilities Serve as the clinical supervisor of an interdisciplinary care team, overseeing chronic condition management, education, care plan development, self-management coaching, social support, and medical escalations. Effectively build trust with our SMG and Community providers, acting as a liaison between them and our care team; demonstrate sound discernment around appropriateness of engagement and escalation across a wide range of patient needs and issues. Bring an adeptness patient data analysis to direct patient engagement, assessment, and care plan formulation. Oversee care team performance by monitoring quality and patient outcomes. Assure care teams proactively identify emerging complications and rising risks with appropriate provider escalations. Monitor hospitalizations, analyze utilization and quality metric trends to direct care team prioritizations. Embrace a role in education and training across our interdisciplinary care team; participate in training and support the delivery of ongoing education of the population health team. Direct and support implementation of proactive care plans based on patients' needs and risk levels. Direct ongoing assessment and monitoring of patients' chronic conditions. Respond to clinical escalations from RNCMs, triage based upon clinical need and support escalation to providers, local pharmacy, or other services, as needed to ensure timely resolution of medical needs. Direct and monitor performance of weekly interdisciplinary team rounds led by the RNCM. Work closely with providers to address complex cases and bring solutions to the population health care team, supporting continuous learning. Ensure accurate coding and documentation of patient interactions and interventions, individually and across our care teams. Qualifications Active and unrestricted Registered Nurse and Nurse Practitioner license. Board certified by ANCC or AANP. Current and unrestricted DEA certificate. Ability to work without direct supervision and practice autonomously. Must be able to effectively identify opportunities for improvement in clinical and operational performance. NP with a strong clinical background and 5 years’ experience in outpatient primary care Experience in accountable care organizations and/or population health care management. Experience in care coordination and quality improvement, including data management. Recent experience in performance improvement as a team member or facilitator. Training in quality/performance improvement strongly desired. Must have strong skills in data interpretation and translation. Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology. Sound understanding of all federal and state regulations including HIPAA and OSHA. Proven knowledge of disease diagnosis and prevention. Willingness to obtain other licensure in states when requested for business needs. Ability to travel domestically as needed. Ability to be flexible to accommodate work teams and members. Must have Reliable transportation. 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. IND1
