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

The Blue Venture Fund; Mobile (AL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health coverage

Paid Time Off

Professional development

Job summary

Somatus is seeking an RN Care Manager, VBC focused on high-needs CKD and ESKD populations, to coordinate care with patients and nephrology practices, building trust and ensuring adherence to treatment plans.

The role requires in-home and clinic visits, collaboration with a multidisciplinary team, and travel across the assigned region to deliver comprehensive care planning and education.

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.
• Valid BLS certification from a licensed AHA or American Red Cross facility.
• Renal, CKD or dialysis care experience as a main focus of your job.
• reside in a location with high-speed internet or access to such service.
• Comfortable traveling to partner hospitals, clinics, and community facilities within assigned region.

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 patients.
• 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 and improve overall patient care.
• Collaborate with provider practices to develop and optimize workflows that align with care team processes.
• Educate provider practices on the Somatus program and reinforce collaborative workflows.
• Provide a complete continuum of quality care through close communication with members via in-person, telehealth or phone interaction, including assessments and reassessments.
• Travel to member homes, facilities, and physician offices to conduct visits and deliver care coordination services.
• Utilize nursing assessment skills to identify barriers affecting the treatment plan.
• In collaboration with nephrologist and team, develop and implement individualized care plans to address needs and remove barriers.
• Manage patients through transitions of care to minimize readmissions.
• Assess discharge knowledge 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

BLS certification

Renal CKD dialysis experience

Travel willingness

Education

BSN or higher

Certified Case Manager (CCM)

Job description

Somatus is seeking an RN Care Manager, VBC focused on high-needs CKD and ESKD populations, to coordinate care with patients and nephrology practices, building trust and ensuring adherence to treatment plans.

The role requires in-home and clinic visits, collaboration with a multidisciplinary team, and travel across the assigned region to deliver comprehensive care planning and education.