Central Nurse

DESCRIPTION:

The Central Nurse is a critical member of the care team working to complete comprehensive assessments, reassessments and care coordination on attributed patients. This position will be working closely with CKD stage 3-5 and ESRD patients by phone or telehealth to create a patient's care plan. The primary focus of the assessment and care plan will be to improve patient outcomes by addressing risks associated with comorbid conditions and coordinating their care. Additional care coordination focus on helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management.

RESPONSIBILITIES:

• Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health.
• Assess the patient's knowledge of their renal condition and provide education and self-management support.
• Based on the assessment, and in conjunction with the patient, patient's nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient

• Create and implement patient care plans to be clearly documented to manage and update with the patient.
• Provide additional support to manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Provide support to engage high risk members in the program by reviewing the patients chart and identifying ways Somatus can support the patient.
• Conduct outreach calls to unengaged patients, complete interdisciplinary care team meetings with special needs population
• Provide clinical coordination to support team of community health workers and licensed care team of social workers and renal dieticians, and delegate tasks as appropriate

• Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s).
• Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility.
• Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions.
• Provide ongoing reassessment and follow-up to improve patient outcomes.
• Provide clinical oversight to non-licensed support team of patient health advocates and licensed support team of social workers and renal dietitians, and delegate tasks as appropriate.

• Provide symptom management education using approved written guidelines as well as approved reference material provided by Somatus.
• Actively participate in new employee orientation, ongoing educational and compliance programs, staff meetings, continuous quality improvement, and performance/protocol evaluations and development
• Maintain current nursing licensure by completing applications for renewal in a timely manner and by complying with all requirements for continuing education.

QUALIFICATIONS:

Required

• 3-5 years of nursing experience in case management or care management, preferably coordinating care across multiple settings
• Able to work on multiple projects at once and juggling competing priorities
• Highly organized and able to time manage effectively
• Current, unrestricted compact Registered Nurse license
• Proactively acts as a patient advocate and responds with resolve
• Knowledge and experience to empower patients in self-management and shared decision making
• Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients
• Self-starter and critical thinking skills.

Preferred

• Bachelor's Degree in Nursing
• Experience working with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.)
• Competence using MS Office products, medical records, and telecom devices
• Core values consistent with a patient-centered approach to care that aligns with our company's values: innovation, authenticity, tenacity, empowerment, and collaboration

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely-held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.