Case Manager RN- Bilingual

Somatus - Case Management Nurse (Remote)

As the largest and leading value-based kidney care company, Somatus empowers patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home.

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.

We offer more than 25 Health, Growth, and Wealth Work Perks to help teammates learn, grow, and be the best version of themselves, including:

• 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!

This position is responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. The role includes care management functions on-site or telephonically as needed. This is a fully remote role where compact licensure is strongly preferred.

The schedule includes some evening hours where you will be expected to work until approximately 8pm, based on member availability. Example: 11am-8pm OR a split shift 8am-12pm and then 4pm-8pm.

• Consistently exhibit behavior and communication skills that demonstrate our company's commitment to superior customer service.
• Prioritize patient care needs upon initial visit and address emerging issues.
• Meet with patients, patients’ family and caregivers to discuss care and treatment plan.
• Identify and assist with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings.
• Consult with physician and other team members to ensure that care plan is successfully implemented.
• Coordinate treatment plans with the care team and triage interventions appropriate to the skill set of the team members.
• Use protocols and pathways in line with established disease management and care management programs and approved by medical management to optimize clinical outcomes.
• Monitor and coach patients using techniques of motivational interviewing and behavioral change to maximize self-management.
• Oversee provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., to maintain continuity of care.
• Work in coordination with the care team and demonstrate accountability with patient management and outcome.
• Discuss Durable Power of Attorney (DPoA) and advanced directive status with PCP when applicable.
• Maintain effective communication with physicians, hospitalists, extended care facilities, patients and families.
• Provide accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues.
• Participate actively in assigned Care Management Coordination Committee (CMCC) meetings.
• Document pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate.
• Coordinate care with central departments on assigned patient caseload, including out-of-area, inpatient central and transplant.
• Adhere to departmental policies and procedures as approved by Office of the…