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Somatus is a leading provider of outcomes-driven care for individuals and communities living with chronic conditions. The Patient Health Advocate (PHA) role supports high-needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations, serving as the primary Somatus representative within physician practices and the first point of contact for building trust and relationships with partnered physicians and practices.
You will work in a hybrid telehealth environment combining remote work with in-home visits and time spent in physician offices. You will work under the guidance of practice physicians and nurse care managers, partnering closely with physicians and office staff to improve patient care and support clinical and operational goals.
Key responsibilities include:
- Conduct patient outreach (telephonic and in-person) to introduce the Somatus program, encourage enrollment, and engage patients
- Serve as the 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 and facilitate effective post-discharge follow-up
- Help patients access community and government-based services and resources
- Address language and cultural barriers to care management and self-care
- Coach and guide patients to meet personal and clinical goals using motivational interviewing techniques
- Schedule provider appointments on behalf of patients and accompany them when needed
- Facilitate closing gaps in care by reinforcing education about preventive monitoring and diagnostic testing
- Support care team members by facilitating in-home telehealth visits
- Document all activities in the care coordination platform in collaboration with physician practices
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
- Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility
- Demonstrated success working as part of a multi-disciplinary team with physicians and registered nurses
- Effective written and verbal communication skills with respect and cultural awareness
- Computer proficiency with MS Office (Word, Excel, PowerPoint, Outlook) and telecom devices
- Proven experience engaging patients in healthy behavior changes
- Ability to navigate health systems and make necessary linkages
- Valid driver's license and ability to travel throughout assigned region for home, provider, and facility visits
- Ability to reside in a location with high-speed internet access and maintain a private, dedicated home workspace compliant with HIPAA regulations
- 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
