Registered Nurse Care Manager - Case Management
Posted on: November 19, 2023
Registered Nurse Care ManagerDESCRIPTION:
The RN Care Manager is a critical member of the care team
consisting of nurses, dietitians, pharmacists, social workers,
community health workers, and physicians. This position will be
working closely with complex renal patients in their home, dialysis
center, by phone and electronically as needed. The primary focus
will be to improve patient outcomes by helping patients get
permanent access, promoting home dialysis modalities & kidney
transplantation, educating patients on self-management, addressing
risks associated with comorbid conditions, and coordinating their
* Conduct comprehensive assessments that include the medical,
behavioral, pharmaceutical, and social needs of the patient,
identify gaps in care and barriers to good health; The RN Care
Manager is expected to conduct approximately 12 assessments per
week and manage a panel of about 150 assessed patients.
* Based on this 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
* 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
* Manage patients during periods of transitions of care to
facilitate effective transitions and minimize avoidable
* Assess the patient's knowledge of their renal condition and
provide education and self-management support;
* Provide ongoing reassessment and follow-up to improve patient
* Provide clinical oversight to non-licensed support team of
community health workers and health coaches and licensed support
team of social workers and renal dietitians, and delegate tasks as
MEASURES OF SUCCESS:
* Provider Relationships.
* Dialysis Interventions monitoring and coordination.
* Medical Management.
* 1+ years of nursing experience in case management or care
management, preferably coordinating care across multiple
* Current Registered Nurse license.
* Core values consistent with a patient-centered approach to
* Proactively acts as a patient advocate and responds with
* Knowledge and experience to empower patients in self-management
and shared decision making.
* Enjoys working collaboratively with team members.
* Effective written and verbal communication skills demonstrating
respect and cultural awareness during interactions with
* Strong analytical and critical thinking skills. Strong community
engagement and facilitation skills.
* Ability to travel throughout the assigned region and comfort with
conducting home visits (up to 50% same day travel).
* Bachelor's Degree in Nursing.
* Demonstrates empathy, enthusiasm, a great sense of humor, and a
strong work ethic.
* Experience working with vulnerable patient population (ESRD,
geriatrics, minorities, low income, uninsured, etc.).
* Ability to establish rapport with patient and family by inquiring
* Familiar with electronic medical records.
* Community Outreach experience, preferred.
* Competence using MS Office products and telecom devices.
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. 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
Keywords: Somatus, Beaumont , Registered Nurse Care Manager - Case Management, Executive , Beaumont, Texas
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