Overview As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home. It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you? Showing Up Somatus Strong We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: Authenticity: We believe in real dialogue. In any interaction, with patients, partners, vendors, or our teammates, we are true to who we are, say what we mean, and mean what we say. Collaboration: We appreciate what every person at Somatus brings to the table and believe that together we can do and achieve more. Empowerment: We make sure every voice gets heard and all ideas are considered, especially when it comes to our patients’ lives or our partners’ best interests. Innovation: We relentlessly look for ways to improve upon the status quo to continuously deliver new solutions. Tenacity: We see challenges as opportunities for growth and improvement — especially when new solutions will make a difference for our patients and partners. Showing Up for You We offer more than 25 Health, Growth, and Wealth Work Perks to help teammates learn, grow, and be the best version of themselves, including: Subsidized, personal healthcare coverage (medical, dental vision) Accrual of 3 weeks’ Vacation (PTO) Professional Development, CEU, and Tuition Reimbursement Curated Wellness Benefits supporting teammates physical and mental well-being Community engagement opportunities And more! Collaborate with local leadership and/or provider engagement to build relationships with case management teams at strategic facilities in assigned area as identified by the Operations Manager, provide information and education on Somatus program benefits to hospital staff within the hospital with intent to increase awareness and engagement in Somatus programs. This position will be focused on high needs chronic kidney disease (CKD) and End-Stage Kidney Disease (ESKD) populations frequently admitted to the hospital and that face multiple challenges, from accessing resources to adhering to a physician’s treatment plan upon discharge. The Hospital Liaison will work with the RNCM, case management and care givers to identify barriers in safe discharge and assist in obtaining resources as needed. Responsibilities Identify members admitted to assigned hospitals & collaborate with Case Managers on appropriate discharge needs of those members. Hospital Liaison will make contact and engage members, establish positive, supportive relationships with members as first point of contact Introduce new eligible hospitalized members to the program, educate on benefits, and obtain consent to the program. Align with post acute facilities and collaborate on appropriate discharge needs of members as needed Work with care team members to address social determinants of members health that may impact treatment and assist with identifying community resources to address needs. Collaborate with Transition of Care Team to identify needs and/or barriers Identify discharge dates and assist with setting Transitions of Care program expectations Coordinate post discharge support and follow up for the member which may include a post-discharge home visit Collaborate with RNCM in the field to identify members with frequent admissions and develop ongoing conversations and plans to address areas to reduce admissions and cost utilization Other duties as assigned 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 Familiar with Medicare, Medicaid or Special Needs population Knowledge of discharge planning process 3-5 years experience with EMR (Electronic Medical Records) systems Minimum three (3) years working with patients with chronic and/or behavioral health needs Ability to be credentialed in local hospital system. Preferred but not required Three (3) years demonstrated success in working as part of a multi-disciplinary team to include working with Physicians. CCHW, MA or CNA certification Knowledge, Skills, and Abilities Effective written and verbal communication skills with internal and external entities Establish and nurture positive working relationships with hospital team and Somatus field care teams. Familiar with local community resources Highly organized and able to manage time effectively 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. All requests for proof of vaccination or for exemptions from the vaccination requirement will be subject to any limitations stipulated by current state and/or federal laws. 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.