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Somatus is a leading provider of outcomes-driven care for individuals living with chronic conditions. The Patient Health Advocate (PHA) role supports high-needs patients with Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD), working closely with Somatus patients and physician practices to establish trust, coordinate care, and improve health outcomes.
You will work in a hybrid telehealth environment combining remote work with in-person visits to members' homes and physician offices. You'll serve as the primary Somatus representative within partnered physician practices, building collaborative relationships with physicians and office staff.
Key responsibilities include:
- Conduct patient outreach (telephonic and in-person) to introduce the Somatus program, encourage enrollment, and engage patients
- Serve as primary contact for provider practices regarding patient needs and care coordination
- Support preparation and management of monthly integrated, interdisciplinary care team meetings
- Assist patients during transitions of care to minimize avoidable readmissions
- Help patients access community and government-based services and resources
- Coach and guide patients to meet personal and clinical goals using motivational interviewing techniques
- Schedule provider appointments and accompany patients when needed
- Address language and cultural barriers to care management
- Support telehealth visits and reinforce patient education
- Document all activities in the care coordination platform
- Collaborate with Registered Nurse Care Managers (RNCM) and care teams
You will work under the guidance of practice physicians and/or a nurse care manager, focusing on improving care delivery and supporting both clinical and operational goals.
Requirements:
- High school diploma or equivalent
- 1+ years of experience in case management or care management, preferably coordinating care across multiple settings
- 2+ years of healthcare-related experience
- Experience working with Medicare, Medicaid, and/or Special Needs populations
- Experience working in a physician office
- Valid driver's license and ability to travel throughout assigned region
- Ability to obtain BLS certification from licensed American Heart Association or American Red Cross training facility
- Proof of COVID-19 vaccination, annual Influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB required for employment
- High-speed internet access and private, dedicated home workspace compliant with HIPAA regulations
- Ability to remain seated or standing for extended periods
Preferred Qualifications:
- Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, or Community Health Worker experience
- Exposure to renal patients
- Bilingual in Spanish, Cantonese, or Mandarin with ability to converse fluently in clinical settings using clinical terms
Desired Skills:
- Demonstrated success working in multi-disciplinary teams with physicians and registered nurses
- Effective written and verbal communication with cultural awareness
- Proficiency with MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices
- Proven experience engaging patients in healthy behavior changes
- Strong navigation skills within health systems
- Self-motivated with strong work ethic and patient-centered approach
