Patient Health Advocate- VBC

Patient Health Advocate (PHA) RoleAs a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus is helping patients across the country enjoy More Healthy Days at Home™.Care at Somatus goes beyond treatment. Through a whole-person approach, we deliver outcomes-driven integrated care and show up #SomatusStrong for our patients and teammates. We partner closely with health plans, health systems, and provider groups to support patients with, or at risk of developing, cardio, kidney, metabolic, or other chronic conditions.We hire the brightest and boldest — talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn't just a milestone — it's a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence.Does this sound like you? Keep reading.The Patient Health Advocate (PHA) role supports Somatus high needs Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD) populations that face multiple challenges, from accessing resources to adhering to a physician's treatment plan. The PHA for VBC will work closely with Somatus patients and physician practices, including spending time working from within physician offices and will be the first and primary representative of Somatus, responsible for establishing trust and building relationships with the partnered physicians and practices.Somatus offers a Hybrid Telehealth environment with a combination of remote days and visits to members' homes.Works under the guidance of practice physicians and/or a nurse care manager.Partners closely with physicians and practice office staff to build a positive, collaborative relationship focused on working together to improve care for patients, support clinical and operational goals, and improves Somatus' primary representative in the practice.Supports the preparation and management of the regular integrated, interdisciplinary care team meetings each month.Serve as primary contact for provider practice regarding patient needs and care coordination.Follow-up with health management plans and goals in coordination with the RNCM.Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.Educates the provider practice about the Somatus program, reinforcing collaborative workflows.Functions as an advocate for the patient and support the patients throughout their journeys.Conduct patient outreach (i.e., telephonic and in-person) to introduce and align patients to the Somatus program, encourage enrollment, and engage patients.Conduct outreach to members currently or recently in the inpatient setting to engage in the Somatus program and/or connect with a Transitions of Care RN to complete an assessment.Assist patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.Assist members in scheduling appointments for follow-up post-discharge from the inpatient setting with their provider.Schedule members for initial and subsequent Somatus assessments with the RNCMUse the care coordination platform to document all activities in collaboration with physician practices.Engages with patients who need assistance with self-care needs, such as:Address language and cultural barriers to care management and self-care.Coach and guide the patient to meet both personal and clinical goals.Schedules provider appointments on behalf of their patients.Accompanies patients to their appointments when needed.Reminds patients of their upcoming appointments.Helps patients access community and government-based services and resources.Helps to reinforce education provided to the patient and/or caregiver about symptom response plans.Arranges transportation.Facilitates closing gaps in care by reinforcing education to patients about preventive monitoring and collaborating with physician practices to schedule / complete diagnostic testing.Assists patients with access to educational videos.Support NP and RNCM care team members by facilitating in-home telehealth visits with patients.Utilize motivational interviewing techniques to encourage patients to make behavioral changes.Qualifications:High school diploma or equivalent required.1+ years of experience in case management or care management, preferably coordinating care across multiple settings.2+ years healthcare related experience.Experience working with Medicare, Medicaid, and/or Special Needs populations.Experience working in a physician office.Preferred Qualifications:Medical Assistant, Licensed Practical Nurse, Patient Care Technician, Engagement Specialist, Community Health Worker experience, or exposure to Renal patients.Bilingual in either Spanish, Cantonese, or Mandarin, with the ability to converse fluently in a clinical setting using clinical terms.Knowledge, Skills, and Abilities:Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Physicians and Registered Nurses.Effective written and verbal communication skills that demonstrate respect and cultural awareness during interactions with patients and clients.Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), and telecom devices including the ability to type and talk at the same time while navigating multiple applications.Ability to obtain valid BLS certification from a licensed American Heart Association or American Red Cross training facility as needed.Proven experience with engaging patients in making healthy behavior changes.Proven skills in navigating the health systems and making necessary linkages to meet specific needs.Ability to consult with physicians and other team members to ensure that care plan is successfully implementedParticipate actively in assigned Care Management Coordination Committee (CMCC) meetingsCore values consistent with a patient-centered approach to careAbility to adapt to changing work environment based on member and client needsAdheres to departmental policies and proceduresSelf-motivated with a strong work ethicPhysical Requirements:Reside in a location that can receive a high-speed internet connection or can leverage existing high-speed internet serviceAccess to a private, dedicated home workspace free from distractions to protect patient privacy regarding HIPAA and Privacy regulationsAbility to travel throughout the assigned region to conduct home, provider, or facility visits, based on the assigned market needs.Ability to work the assigned schedule to meet the client and patient's needs.Ability to remain in a seated or standing position for extended periods of time as required to perform essential job functions.This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Our priority is the health and safety of our members, colleagues, partners, and community. For this position, we require proof of COVID-19 vaccination, annual Influenza vaccination, along with immunizations for Hepatitis, MMR, Varicella, Tdap, and TB for employment.At Somatus, we celebrate what makes us unique — our people. We believe that a culture intentionally built to foster and support our unique passions, experiences, and perspectives helps fuel us in the pursuit of our mission.Somatus, Inc. provides equal employment opportunity to all individuals regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by law. Discrimination of any type will not be tolerated.