Nurse Care Coordinator

2 weeks ago

Terre Haute, Indiana, United States Somatus Full time
Position Overview


As a leading value-driven organization in kidney care, Somatus is dedicated to enhancing the lives of individuals living with chronic kidney disease. Our mission is to ensure patients experience fewer hospital days and improved health at home.


We believe that a collaborative and innovative approach is essential to transform the healthcare landscape and support those managing chronic conditions.


Core Values
Our values are the foundation of our mission and guide every decision we make:

  • Authenticity: We engage in genuine conversations with patients, partners, and colleagues, staying true to our principles.
  • Collaboration: We value the contributions of every team member, believing that together we can achieve greater outcomes.
  • Empowerment: We ensure that every voice is heard and that all ideas are valued, particularly regarding patient care.
  • Innovation: We continuously seek to enhance existing practices to deliver effective solutions.
  • Tenacity: We view challenges as opportunities for improvement, especially when they can positively impact our patients.


What We Offer
We provide a comprehensive benefits package designed to support our team members' health, growth, and financial well-being, 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 benefits promoting physical and mental health
  • Community engagement initiatives
  • And more


Role Summary
The RN Care Manager plays a vital role within a multidisciplinary care team, which includes nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position focuses on collaborating with complex renal patients through various means, including home visits, telehealth, and electronic communication.


The primary goal is to enhance patient outcomes by:

  • Facilitating permanent access to care
  • Promoting home dialysis options and kidney transplantation
  • Educating patients on self-management techniques
  • Addressing risks associated with comorbidities
  • Coordinating comprehensive care


Key Responsibilities
As an RN Care Manager, you will:

  • Conduct thorough assessments covering medical, behavioral, pharmaceutical, and social needs, identifying care gaps and health barriers. The expectation is to perform approximately 12 assessments weekly and manage a panel of around 150 patients.
  • Develop and implement personalized care plans in collaboration with patients, nephrologists, primary care providers, and other team members.
  • Act as an advocate and resource for patients and their families, ensuring seamless care coordination across various settings.
  • Manage transitions of care to minimize avoidable readmissions.
  • Educate patients about their renal conditions and support self-management.
  • Provide ongoing assessments and follow-ups to enhance patient health outcomes.
  • Oversee non-licensed support staff and delegate tasks as appropriate.


Success Metrics
Your performance will be evaluated based on:

  • Quality of provider relationships
  • Effectiveness of dialysis interventions
  • Overall medical management


Qualifications
Required:

  • Minimum of 1 year of nursing experience in case or care management, ideally across multiple healthcare settings.
  • At least 2 years of healthcare-related experience.
  • Current, unrestricted compact Registered Nurse license.
  • Valid BLS certification from an accredited provider.
  • Commitment to a patient-centered care approach.
  • Strong communication skills and cultural awareness.
  • Ability to travel within the assigned region and conduct home visits as necessary.


Preferred:

  • Bachelor's degree in nursing.
  • Experience with vulnerable populations, including those with end-stage renal disease, geriatrics, and low-income individuals.
  • Familiarity with electronic medical records and community outreach.
  • Proficiency in MS Office and telecommunications.


Please note that this job description is not exhaustive and may be subject to change. Somatus, Inc. is an equal opportunity employer, committed to diversity and inclusion in the workplace.

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