Patient Health Advocate (TOC)

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 

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).

• 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:

• Experience working with Medicare, Medicaid or Special Needs populations.
• High school diploma or GED required .
• 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 Qualifications:

• 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

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.