Patient Health Advocate – Lead

Overview: This position will be focused on 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.
Serves as liaison to the LCSW and functions as mentor to peer PHAs on local community Social Determinants of Health (SDOH) resources.
Responsibilities: Works under the guidance of practice physicians and/or a nurse care manager.
Partners closely with peers and LCSW and serves as a conduit for information.
Ability to build a collaborative relationship focused on removing SDOH barriers to improve care for patients.
Helps the care team prepare and manage the regular integrated, interdisciplinary care team meetings each month.
Co-Lead weekly meetings with LCSW and SW team.
Serve as primary contact for PHAs needing assistance navigating resources and applications.
Follow-up with health management plans and goals in coordination with the RNCM, LCSW and peer PHAs.
Establish and maintain team community resource page.
Triage questions and concerns of PHAs, serve as liaison between PHAs and SW and Management for questions not currently answered in the resource page.
Keeps the team resource page up to date and easy to navigate with current policies and procedures for concrete services, validate and add resources as they become available.
Function as an advocate for the patient and support the patients throughout their journeys.
Conduct outreach (i.
e.
, telephonic and in-person) to patients to introduce the Somatus program, encourage enrollment and engage patients.
Conduct an initial outreach query and discussion to help align patients with the most appropriate program in accordance with program guidelines.
Schedule members for initial and subsequent Somatus assessments with the RNCM Documents their activities in the care coordination platform, including care plan activities conducted.
Engages with patients who need assistance with self-care needs in addition to what a nurse care manager can provide via phone, 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.
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.
Qualifications: Required Education and Experience: High school diploma or equivalent.
Experience working with Medicare, Medicaid, or Special Needs populations.
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.
Well connected to the community and exceptional understanding of the resources available to their patient population.
Strong written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients and in physician offices.
Experience working in a high-volume environment.
Preferred but not required 3-5 years’ experience in a Somatus PHA role.
Bachelors degree or equivalent.
Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker experience.
Knowledge, Skills, and Abilities: Excellent and timely communication skills via Outlook and Teams Content Expert on PHA responsibilities and role Demonstrated leadership skills.
Experience collaborating with patients with chronic and behavioral health needs.
Demonstrated success in working as part of a multi-disciplinary team including communicating and collaborating with interdisciplinary teams.
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.
Can speak other language(s).
Experience working with Electronic Medical Record systems and other documentation platforms.
Initiative-taker – able to prioritize and drive to completion.
Ability to travel throughout the assigned region and comfort with conducting home visits when required.
Ability to establish rapport with peers, patients, families, and community resource organizations.
Outgoing personality with ability to speak clearly and with confidence to peers, patients, and providers in a variety of settings, Ability to adapt to change quickly.
Ability to work within a demanding environment.
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.