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Nurse Care Coordinator

2 months ago

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Position Overview

As a prominent leader in value-based kidney care, Somatus is dedicated to enhancing the lives of individuals managing chronic kidney disease, enabling them to spend more time at home and less in healthcare facilities.

Our mission is supported by a team of innovative and committed professionals who are transforming the healthcare landscape for those living with chronic conditions. Do you resonate with this vision?

Our Commitment to a Supportive Work Culture

We cultivate an inclusive workplace that encourages teamwork and creativity at every level. Our core values are the foundation of our mission and guide every decision we make:
  • Authenticity: We prioritize genuine communication, ensuring that our interactions with patients, partners, and colleagues reflect our true selves.
  • 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 are committed to continuously seeking improvements to deliver effective solutions.
  • Tenacity: We view challenges as opportunities for growth, especially when they lead to better patient outcomes.

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)
  • Opportunities for professional development, continuing education units (CEUs), and tuition reimbursement
  • Wellness programs that promote 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 involves working closely with patients experiencing complex renal conditions in various settings, including their homes and healthcare facilities. The primary goal is to enhance patient outcomes by:
  • Facilitating permanent access to care, promoting home dialysis options, and supporting kidney transplantation.
  • Educating patients on self-management techniques and addressing risks associated with comorbidities.
  • Coordinating comprehensive care tailored to individual patient needs.

Key Responsibilities

  • Conduct thorough assessments of patients' medical, behavioral, pharmaceutical, and social needs, identifying care gaps and barriers to health. The RN Care Manager is expected to perform approximately 12 assessments weekly and manage a panel of around 150 patients.
  • Collaborate with patients, nephrologists, primary care providers, and other care team members to develop and implement personalized care plans.
  • Act as an advocate and resource for patients and their families, ensuring seamless care coordination.
  • Facilitate transitions of care across various settings, including home, hospital, and skilled nursing facilities.
  • Provide education and ongoing support to patients regarding their renal health and self-management strategies.
  • Oversee non-licensed community health workers and licensed social workers and dietitians, delegating tasks as appropriate.

Success Metrics

  • Building strong 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.
  • At least 2 years of experience in a healthcare-related role.
  • Current, unrestricted compact Registered Nurse license.
  • All team members must maintain valid BLS certification from an accredited provider.
  • Core values aligned with a patient-centered approach.
  • Proactive patient advocacy and problem-solving skills.
  • Ability to empower patients in self-management and shared decision-making.
  • Strong collaborative skills with team members.
  • Effective communication skills, demonstrating respect and cultural sensitivity.
  • Analytical and critical thinking abilities, along with community engagement skills.
  • Willingness to travel within the assigned region and conduct home visits as necessary.

Preferred:
  • Bachelor's degree in nursing.
  • Demonstrated empathy, enthusiasm, and a strong work ethic.
  • Experience with vulnerable populations, including those with end-stage renal disease, geriatrics, and low-income individuals.
  • Ability to build rapport with patients and families through active listening.
  • Familiarity with electronic medical records.
  • Experience in community outreach.
  • 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 in accordance with applicable laws. Somatus, Inc. is an equal opportunity employer, committed to diversity and inclusion in the workplace.