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! The 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 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 Required Education and Experience 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 serve Physical 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 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.