Field-Based RN Care Manager: CKD/ESKD Home Visits

Socket.dev; Cincinnati (OH); On-site; USD 80,000 - 90,000; Full time

Benefits offered by this job

Subsidized personal healthcare

Paid Time Off

Professional development

Job summary

Somatus is seeking an RN Care Manager, VBC to support high-need CKD/ESKD populations across assigned regions. You will partner with nephrologists, PCPs, and interdisciplinary teams to coordinate care, remove barriers, and implement individualized care plans that improve patient outcomes.

You’ll conduct home, clinic, and facility visits, perform comprehensive assessments, educate patients on discharge requirements and self-management, and travel up to 75% of the time.

Qualifications

• RN license and ability to get licensed in other states as needed.
• 2+ years of RN experience, including working as part of a multi‑disciplinary team and Physicians.
• BLS certification from a licensed facility.
• Renal CKD or dialysis care experience as a main focus of your job.
• Reside in a location that can receive a high‑speed internet connection or can leverage existing high‑speed internet service.
• Comfortable traveling to partner hospitals, clinics, and community‑based facilities within your assigned region to support care coordination.

Responsibilities

• Partner closely with physicians and practice staff to establish a collaborative working relationship focused on improving patient outcomes.
• Support the care team in planning, coordinating, and facilitating regular interdisciplinary care team meetings with partnered practices to improve outcomes for complex, high-priority patients.
• Establish and maintain positive, supportive relationships with patients and provider offices through in‑person and telephonic engagement.
• Develop strong partnerships with provider practice teams to support both clinical and operational goals and improve the overall quality of patient care.
• Collaborate with provider practices to develop and optimize workflows that align with operational objectives and care team processes.
• Educate provider practices on the Somatus program and reinforce collaborative, integrated workflows.
• Provide a complete continuum of quality care through close communication with members via in‑person, telehealth or on‑phone interaction, including comprehensive assessments, transitional care assessments and reassessments.
• Travel to member homes, facilities, and physician offices to conduct visits, participate in care planning, and deliver care coordination services.
• Utilize nursing assessment skills to identify medical, behavioral, and social determinants of health barriers affecting the treatment plan.
• In collaboration with the patient, nephrologist, PCP, and interdisciplinary care team, develop and implement individualized care plans to address identified needs, remove barriers to care, and improve overall health outcomes.
• Manage patients through transitions of care by supporting effective handoffs and minimizing preventable readmissions.
• Assess the patient’s knowledge of their discharge care requirements and renal condition and provide education and self‑management support.
• Provide clinical guidance and oversight to both non‑licensed (community health workers, health coaches) and licensed (social workers, renal dietitians) team members, delegating tasks as appropriate.
• Perform other duties as assigned.

Skills

RN license

RN experience (2+)

BLS certification

Renal CKD or dialysis experience

Reliable internet access

Willingness to travel

Education

BSN or higher

CCM certification

Tools

MS Office Suite

Telecom devices

Job description

Somatus is seeking an RN Care Manager, VBC to support high-need CKD/ESKD populations across assigned regions. You will partner with nephrologists, PCPs, and interdisciplinary teams to coordinate care, remove barriers, and implement individualized care plans that improve patient outcomes.

You’ll conduct home, clinic, and facility visits, perform comprehensive assessments, educate patients on discharge requirements and self-management, and travel up to 75% of the time.