Registered Nurse Care Manager VBC, Kidney Disease & Chronic Care at Somatus
Overview
The RN Care Manager will own high‑needs CKD and ESKD patient care programs at scale within Somatus partner networks. You will collaborate with physicians, health plans, and interdisciplinary teams to deliver outcomes‑driven, patient‑centered care in home, clinic, and facility settings. This role emphasizes field nursing, care coordination, and integral partner relationships to improve outcomes and reduce readmissions. What makes this role distinct is its physician practice partnership focus and emphasis on whole‑person care that spans clinical and social determinants of health.
What You'll Do10
- 1Build and maintain trusted relationships with nephrology practices to drive collaborative care and outcomes
- 2Schedule and conduct in‑person and telehealth visits to assess barriers and educate patients on care plans
- 3Partner with physicians and health teams to plan, coordinate, and facilitate interdisciplinary care team meetings
- 4Educate provider practices on the Somatus program and integrate workflows across settings
- 5Develop individualized care plans with nephrologists, PCPs, and care teams to address identified needs
- 6Manage transitions of care to minimize preventable readmissions and ensure continuity of care
- 7Provide clinical guidance to non‑licensed and licensed team members and delegate tasks as appropriate
- 8Travel to patient homes, dialysis clinics, and offices to deliver care coordination services
- 9Assess social determinants of health and behavioral barriers and tailor interventions
- 10Maintain documentation and communication across members, providers, and care teams to support quality improvements
Requirements9
- 1RN license with ability to obtain licensure in additional states as needed
- 22+ years of RN experience in multidisciplinary team settings with physicians
- 3Valid BLS certification from an AHA or American Red Cross facility
- 4Renal, CKD, or dialysis care experience as a main focus
- 5Ability to travel locally to partner hospitals, clinics, and community facilities
- 6High‑speed internet access or ability to leverage existing service
- 7willingness to travel 75% of the time for field visits
- 8Reside in a location within service region to support care coordination
- 9Commitment to ADA accommodations as needed and COVID‑19 vaccination requirements
Salary Insight
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