RN Care Manager — CKD/ESKD Field-Based Care

Socket.dev; Tyler (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Somatus is seeking an RN Care Manager to support high-need CKD/ESKD patients through field visits to homes, clinics, and facilities. You will collaborate with nephrologists, PCPs, and an interdisciplinary team to develop and implement individualized care plans and to remove barriers to care.

You will educate patients and families, coordinate transitions of care, and travel within your assigned region to improve outcomes while adhering to HIPAA and quality standards.

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 with physicians.
• Valid BLS certification ONLY from a licensed AHA or American Red Cross facility.
• Renal, Chronic Kidney Disease or Dialysis care experience as a main focus of your job.
• Reside in a location with high-speed internet or can leverage existing service.
• Comfortable traveling to partner hospitals, clinics, and community facilities within your assigned region.

Responsibilities

• Partner closely with physicians and practice staff to establish collaborative relationships focused on improving patient outcomes.
• Support the care team in planning, coordinating, and facilitating regular interdisciplinary care team meetings with partnered practices.
• Establish and maintain positive relationships with patients and provider offices through in-person and telephonic engagement.
• Develop partnerships with provider practice teams to support clinical and operational goals.
• Collaborate with provider practices to develop and optimize workflows that align with care team processes.
• Educate provider practices on the Somatus program and reinforce integrated workflows.
• Provide a complete continuum of quality care through close communication with members via in-person, telehealth or phone, including assessments and reassessments.
• Travel to member homes, facilities, and physician offices to conduct visits and deliver care coordination services.
• Use nursing assessment skills to identify barriers affecting the treatment plan.
• Develop and implement individualized care plans with the patient and team.
• Manage transitions of care and minimize readmissions.
• Provide education on discharge requirements and renal condition.
• Provide clinical guidance to non-licensed and licensed team members.

Skills

RN license

RN experience

BLS certification

Renal/Kidney disease care

Travel to partner hospitals

Internet access at home

Education

BSN or higher

Job description

Somatus is seeking an RN Care Manager to support high-need CKD/ESKD patients through field visits to homes, clinics, and facilities. You will collaborate with nephrologists, PCPs, and an interdisciplinary team to develop and implement individualized care plans and to remove barriers to care.

You will educate patients and families, coordinate transitions of care, and travel within your assigned region to improve outcomes while adhering to HIPAA and quality standards.