at Somatus in Joliet, Illinois, United States
Job Description
Overview
This position will be focused on high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations that face multiple challenges, from accessing resources to adhering to a physician’s treatment plan. The Patient Health Advocate – Practice Lead will work closely with Somatus patients and physician practices, including spending time working from within physician offices. The Patient Health Advocate – Practice Lead will be the first and primary representative of Somatus to partnered physician practices. He/she will be the key team member to establish trust with physicians and practices and will be responsible for building this relationship.
The Patient Health Advocate – Practice Lead will work as an extension of Somatus’ clinical care team, specifically under the guidance of a renal nurse care manager. The individual taking this role will manage his/her caseload through in-person, telephonic and electronic means of communications and coordination. This position is a market-based position.
Responsibilities
+ Works under the guidance of practice physicians and/or a nurse care manager.
+ Partners closely with physicians and practice office staff to build a collaborative relationship focused on working together to improve care for patients. Built relationships over time as Somatus’ primary representative in the practice.
+ Helps the care team prepare and manage the regular integrated, interdisciplinary care team meetings each month.
+ Serve as primary contact for provider practice regarding patient needs and care coordination.
+ Follow-up with health management plans and goals in coordination with the RNCM.
+ Establish positive, supportive relationships with patients and physician offices and provides feedback through in-person and telephonic interactions.
+ Builds relationships with the provider practice team to support clinical and operational goals and help improve patient care.
+ Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.
+ Educate the provider practice about the Somatus program, reinforcing collaborative workflows.
+ Function as an advocate for the patient and support the patients throughout their journeys.
+ Conduct outreach (i.e., telephonic and in-person) to patients to introduce the Somatus program, encourage enrollment and engage patients.
+ Conduct an initial outreach query and discussion to help align patients with the most appropriate program in accordance with program guidelines.
+ Schedule members for initial and subsequent Somatus assessments with the RNCM
+ Documents their activities in the care coordination platform, including care plan activities conducted.
+ Engages with patients who need assistance with self-care needs in addition to what a nurse care manager can provide via phone, such as:
+ Address language and cultural barriers to care management and self-care.
+ Coach and guide the patient to meet both personal and clinical goals.
+ Schedules provider appointments on behalf of their patients.
+ Accompanies patients to their appointments when needed.
+ Reminds patients of their upcoming appointments.
+ Helps patients access community and government-based services and resources.
+ Helps to reinforce education provided to the patient and/or caregiver about symptom response plans.
+ Arranges transportation.
+ Facilitates closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule / complete diagnostic testing.
+ Assists patients with access to educational videos.
+ Support NP and RNCM care team members by facilitating in-home telehealth visits with patients.
+ Utilize motivational interviewing techniques to encourage patients to make behavioral changes.
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.
Qualifications
+ High school diploma or equivalent.
+ 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 exceptional understanding of the resources available to their patient population.
+ Strong written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients and in physician offices.
+ Experience working in a high-volume environment.
+ Initiative-taker – able to prioritize and drive to completion,
+ Ability to travel throughout the assigned region and comfort with conducting home visits (50-75% same day travel).
+ Ability to establish rapport with patients, families, and physician offices,
+ Outgoing personality with ability to speak clearly and with confidence to patients and providers in a variety of settings,
+ Ability to adapt to change quickly.
+ Ability to work within a demanding environment.
Knowledge, Skills, and Abilities:
+ Experience working in a physician office.
+ Experience collaborating with patients with chronic and behavioral health needs.
+ Demonstrated success in working as part of a multi-disciplinary team including communicating and collaborating 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 to meet specific needs.
+ Can speak other language(s).
+ Experience working with Electronic Medical Record systems and other documentation platforms.
Physical Requirements
+ The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and listen. The employee is frequently required to stand; walk; use hands to finger, handle and feel; and reach with hands and arms. This position may require standing and walking for long shifts. Seeing, smelling, repetitive motion and lifting objects weighing up to 50 pounds at a time are required for this position.
Other Duties
Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law.
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.
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