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Patient Health Advocate
2 months ago
Company: Somatus, Inc.
Somatus, Inc. is a leading value-based kidney care organization that empowers patients with chronic kidney disease to live healthier lives. We're seeking a passionate and dedicated CHW-Patient Advocate to support our clinical care team in providing personalized support to patients with high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations.
Key Responsibilities:- Work closely with our clinical care team to provide personalized support to patients with high needs CKD and ESKD populations.
- Build and maintain relationships with patients, their families, and healthcare providers to ensure seamless care coordination.
- Establish positive, supportive relationships with participants and provide feedback.
- Conduct an initial triage assessment to help align patients with the most appropriate program in accordance with program guidelines.
- Document activities in the care coordination platform, including care plan activities conducted.
- Engage with patients who need assistance with self-care needs, including addressing language and cultural barriers to care management and self-care.
- Coach and guide patients to meet both personal and clinical goals.
- Schedule provider appointments on behalf of patients and accompany them to appointments when needed.
- Remind patients of upcoming appointments and help them access community and government-based services.
- Teach caregivers about symptom response plans and arrange transportation as needed.
- Closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing.
- Patient Engagement
- Care Setting Transitions
- Assessment
- Monthly Goal completion as set by the RNCM
- Patient Success - as measured by no/reduced hospital or ER visits on a monthly basis
- Experience working with Medicare, Medicaid or Special Needs populations.
- Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker Experience.
- Ability to connect with people and understand the challenges they face.
- Ability to use a range of outreach methods to engage individuals and groups in diverse settings.
- Well connected to the community and resources within the community they will serve.
- Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.
- Ability to travel throughout the assigned region and comfort with conducting home visits (50-75% same day travel).
- Experience working with patients with chronic and behavioral health needs.
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Physicians and Registered Nurses.
- Proven experience with engaging patients in making healthy behavior changes.
- Proven skills in navigating the health systems and making necessary linkages in order to meet specific needs.
- Experience working with Electronic Medical Records and other documentation platform.
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.
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.
