RN Care Manager – Field-Based CKD/ESKD Care Coordination

Somatus; Scottsdale (AZ); Hybrid; USD 80,000 - 90,000; Full time

Benefits offered by this job

Health coverage

PTO

Tuition reimbursement

CEU and tuition reimbursement

Job summary

Somatus is seeking an RN Care Manager, VBC to support high-needs CKD/ESKD patients. You will partner with physicians and practices to coordinate care and educate patients.

In this field-based role, you will conduct home visits, dialysis clinic visits, and telehealth sessions, building trust and improving outcomes. Travel is required within your designated region, with interdisciplinary team collaboration central to care planning.

Qualifications

• RN license and ability to get licensed in other states as needed.
• 2+ years RN experience in a multi-disciplinary team and with physicians.
• Valid BLS certification from an AHA or Red Cross facility.
• Renal, CKD or dialysis care experience as main focus of your job.
• Reside in a location with high-speed internet or can access it; able to travel within assigned region.

Responsibilities

• Partner 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 relationships with patients and provider offices through in-person and telephonic engagement.
• Develop strong partnerships with provider practice teams to support clinical and operational goals and improve overall 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 and reassessments.
• Travel to member homes, facilities, and physician offices to conduct visits and participate in care planning.
• 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 and improve health outcomes.
• Manage patients through transitions of care by supporting handoffs and reducing readmissions.
• Assess patient knowledge of discharge care and renal condition and provide education and self-management support.
• Provide clinical guidance to non-licensed and licensed team members, delegating tasks as appropriate.
• Perform other duties as assigned.

Skills

RN license

RN experience 2+ yrs

BLS certification

Travel willingness

Team collaboration

Education

BSN or higher

CCM certification

Tools

MS Office

Telecom devices

Job description

Somatus is seeking an RN Care Manager, VBC to support high-needs CKD/ESKD patients. You will partner with physicians and practices to coordinate care and educate patients.

In this field-based role, you will conduct home visits, dialysis clinic visits, and telehealth sessions, building trust and improving outcomes. Travel is required within your designated region, with interdisciplinary team collaboration central to care planning.