Patient Health Advocate - Practice Lead

Overview:

How We Show Up for Our Patients:
As a leading provider of outcomes-driven care for individuals and communities living with chronic conditions, Somatus is helping patients across the country enjoy More Healthy Days at Home™.

Care at Somatus goes beyond treatment. Through a whole‑person approach, we deliver outcomes‑driven integrated care and show up #SomatusStrong for our patients and teammates. We partner closely with health plans, health systems, and provider groups to support patients with, or at risk of developing, cardio, kidney, metabolic, or other chronic conditions.

We hire the brightest and boldest — talent driven by purpose and impact. Since our founding in 2016, our growth trajectory isn’t just a milestone — it’s a signal. Our leadership values culture and leads with intention as we remain dedicated to driving clinical excellence.

Does this sound like you? Keep reading.

How We’ll Support You:
We offer 25+ health, growth, and wealth work perks to help teammates be the best version of themselves, including:

• Subsidized personal healthcare coverage: Medical, Dental & Vision, plus Wellness programs
• Paid Time Off: Accrual of 3 weeks’ Vacation (PTO)
• Professional development: CEU and tuition reimbursement

Responsibilities:

How You’ll Make an Impact:

• Works under the guidance of practice physicians and/or a nurse care manager.
• Partners closely with physicians and practice office staff to build a collaborative relationship focused on working together to improve care for patients. Built relationships over time as Somatus’ primary representative in the practice.
• Helps the care team prepare and manage the regular integrated, interdisciplinary care team meetings each month.
• Serve as primary contact for provider practice regarding patient needs and care coordination.
• Follow-up with health management plans and goals in coordination with the RNCM.
• Establish positive, supportive relationships with patients and physician offices and provides feedback through in-person and telephonic interactions.
• Builds relationships with the provider practice team to support clinical and operational goals and help improve patient care.
• Collaborates with the provider practice to build and fine-tune workflows to support operational goals with the RNCM and care team.
• Educate the provider practice about the Somatus program, reinforcing collaborative workflows.
• 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.

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time with or without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications:

How You’ll Strengthen Our Team:

Qualifications:

• High school diploma or equivalent.
• Experience working with Medicare, Medicaid, or Special Needs populations.
• Medical Assistant, Licensed Practical Nurse, Engagement Specialist or Community Health Worker experience.
• 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.
• Initiative-taker – able to prioritize and drive to completion,
• Ability to travel throughout the assigned region and comfort with conducting home visits (50-75% same day travel).
• Ability to establish rapport with patients, families, and physician offices,
• Outgoing personality with ability to speak clearly and with confidence to patients and providers in a variety of settings,
• Ability to adapt to change quickly.
• Ability to work within a demanding environment.

• Experience working in a physician office.
• 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 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.
• Can speak other language(s).
• Experience working with Electronic Medical Record systems and other documentation platforms.

Other Duties : Other Requirements: 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 applicable law. Our Commitment to Diversity: At Somatus, we celebrate what makes us unique — our people. We believe that a culture intentionally built to foster and support our unique passions, experiences, and perspectives helps fuel us in the pursuit of our mission. Somatus, Inc. provides equal employment opportunity to all individuals regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by law. Discrimination of any type will not be tolerated.