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Form of workOverviewThe Patient Health Advocate-Transitions of Care, is a critical member of the care team consisting of nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position will be outreaching and collaborating closely with recently hospitalized complex renal patients in their home, facility, via phone and electronically as needed. The primary focus will be to engage currently or recently hospitalized members in the Somatus program and improve the movement of a patient from one care setting to another (hospital, skilled care, rehab, or long-term care).Responsibilities* 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.* 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.* 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.* Other duties as assignedPlease 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.QualificationsRequired* Experience working with Medicare, Medicaid or Special Needs populations.* Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker experience.* Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients.Preferred* Experience working with patients with chronic medical and behavioral health needs.* Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Physicians and Registered Nurses.* 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.* Experience working with Electronic Medical Records and other documentation platforms.Knowledge, Skills, and Abilities:* Great motivator* Ability to connect with people and understand the challenges they face.* Ability to use a range of outreach methods to engage individuals and groups in diverse settings* Organized Coach* Empathetic* Outgoing / positive personality* Well connected to the community and resources within the community they will servePhysical Requirements* Ability to travel throughout the assigned region and comfortable with conducting home and facility visits (up to 75% same day travel) depending on assigned market.Other DutiesOur 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.
