Nursing Care Coordinator

1 week ago

Newnan, Georgia, United States Somatus Full time
Position Overview

As a premier value-driven kidney care organization, Somatus is dedicated to enhancing the lives of individuals managing chronic kidney disease, enabling them to spend more time at home and less in medical facilities.

We believe that transforming healthcare requires a committed team of innovative thinkers who are passionate about supporting those with chronic conditions. Does this resonate with you?

Our Commitment to Values

At Somatus, we cultivate a workplace that champions collaboration and creativity at every level. Our core values guide our mission and influence every decision we make:
  • Authenticity: We prioritize genuine communication, ensuring that our interactions with patients, partners, and colleagues reflect our true selves.
  • Collaboration: We recognize the unique contributions of each team member and believe that together we can achieve greater outcomes.
  • Empowerment: We ensure that every voice is valued and that all ideas are considered, particularly regarding our patients' well-being.
  • Innovation: We are committed to continuously seeking improvements to deliver effective solutions.
  • Tenacity: We view challenges as opportunities for growth, especially when they lead to better outcomes for our patients and partners.

Benefits for Our Team

We provide over 25 health, development, and financial benefits to support our team members in their personal and professional growth, including:
  • Subsidized healthcare coverage (medical, dental, vision)
  • Accrual of 3 weeks of Paid Time Off (PTO)
  • Professional development opportunities, including CEUs and tuition reimbursement
  • Wellness programs promoting physical and mental health
  • Community involvement initiatives
  • And more

Role of the RN Care Manager

The RN Care Manager plays a vital role within a multidisciplinary care team that includes nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position focuses on collaborating with complex renal patients in various settings, including their homes and through telehealth.

Key Responsibilities

  • Conduct thorough assessments encompassing medical, behavioral, pharmaceutical, and social needs, identifying care gaps and health barriers. The RN Care Manager is expected to perform approximately 12 assessments weekly and manage a panel of around 150 patients.
  • Develop and implement a personalized care plan in collaboration with the patient, their nephrologist, primary care physician, and other care team members based on assessment findings.
  • Act as an advocate and resource for patients, their families, and healthcare providers to coordinate care effectively.
  • Facilitate care transitions across various settings, including home, hospital, and skilled nursing facilities.
  • Support patients during transitions of care to ensure smooth handoffs and reduce avoidable readmissions.
  • Evaluate patients' understanding of their renal conditions and provide education and self-management resources.
  • Perform ongoing assessments and follow-ups to enhance patient outcomes.
  • Oversee non-licensed community health workers and health coaches, as well as licensed social workers and renal dietitians, delegating tasks as appropriate.

Success Metrics

  • Strengthening provider relationships
  • Monitoring and coordinating dialysis interventions
  • Effective medical management

Qualifications

Required:
  • Minimum of 1 year of nursing experience in case management or care coordination, ideally across multiple healthcare settings.
  • At least 2 years of experience in a healthcare-related role.
  • Current, unrestricted compact Registered Nurse license.
  • All team members must maintain current BLS certification from an accredited provider.
  • Core values aligned with a patient-centered care approach.
  • Proactive patient advocacy skills.
  • Ability to empower patients in self-management and shared decision-making.
  • Enjoyment of collaborative teamwork.
  • Strong written and verbal communication skills, demonstrating respect and cultural sensitivity.
  • Excellent analytical and critical thinking abilities, along with community engagement skills.
  • Willingness to travel within the assigned region and conduct home visits as needed.

Preferred:
  • Bachelor's degree in nursing.
  • Exhibits empathy, enthusiasm, a sense of humor, and a strong work ethic.
  • Experience with vulnerable patient populations (e.g., ESRD, geriatrics, minorities, low-income, uninsured).
  • Ability to build rapport with patients and families through active listening.
  • Familiarity with electronic medical records.
  • Experience in community outreach is a plus.
  • Proficiency in MS Office and telecom devices.

Additional Information

Please note that this job description is not exhaustive and may be subject to change. Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 vaccination is required for employment, with reasonable accommodations considered for medical or religious reasons. Somatus, Inc. is an equal opportunity employer, committed to diversity and inclusion in the workplace. Discrimination of any kind is not tolerated.

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