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Somatus is a leading provider of outcomes-driven care for individuals living with chronic conditions, founded in 2016. The Patient Health Advocate (PHA) role supports high-needs patients with Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, working in a hybrid telehealth environment combining remote work with in-home and physician office visits.
You will serve as the primary Somatus representative to partnered physician practices and patients, establishing trust and building collaborative relationships. Key responsibilities include:
- Conduct patient outreach via phone and in-person to introduce the Somatus program, encourage enrollment, and engage patients in care management
- Work closely with physician practices and Registered Nurse Care Managers (RNCM) to coordinate integrated, interdisciplinary care team meetings
- Support patients during transitions of care (e.g., post-discharge) to minimize avoidable readmissions and facilitate effective care coordination
- Assist patients with scheduling appointments, accessing community and government resources, arranging transportation, and addressing language/cultural barriers
- Coach patients using motivational interviewing techniques to support behavioral change and self-care goals
- Document all activities in the care coordination platform and collaborate with physician practices on workflow optimization
- Facilitate in-home telehealth visits and reinforce clinical education about symptom response plans and preventive monitoring
- Serve as the primary contact for provider practices regarding patient needs and care coordination
The role requires travel throughout the assigned region for home, provider, and facility visits based on market needs. You will work under the guidance of practice physicians and/or a nurse care manager, and must maintain a private, dedicated home workspace compliant with HIPAA regulations.
QUALIFICATIONS:
- High school diploma or equivalent (required)
- 1+ years of experience in case management or care management, preferably coordinating care across multiple settings (required)
- 2+ years of healthcare-related experience (required)
- Experience working with Medicare, Medicaid, and/or Special Needs populations (required)
- Experience working in a physician office (required)
- Valid driver's license and ability to travel throughout assigned region
- Ability to obtain BLS certification from American Heart Association or American Red Cross
- Proof of COVID-19 vaccination, annual influenza vaccination, and immunizations for Hepatitis, MMR, Varicella, Tdap, and TB required for employment
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 terminology
KEY SKILLS & ABILITIES:
- Demonstrated success working in multi-disciplinary teams with physicians and registered nurses
- Effective written and verbal communication with cultural awareness
- Computer proficiency in MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices; ability to multitask while navigating applications
- Proven experience engaging patients in healthy behavior changes
- Strong navigation of health systems and ability to make necessary linkages
- Patient-centered approach aligned with core organizational values
- Ability to adapt to changing work environments
- Physical ability to remain seated or standing for extended periods and travel throughout assigned region
