Registered Nurse Case Manager, Level 2

21st Century Home Health Services•Sonoma, CA

22d•Remote

About The Position

At 21st Century Home Health Services (21HHS), we treat every patient with empathy, compassion, and understanding. As the largest home health agency in San Francisco and the fastest-growing in the Bay Area, we care for over 4,000 patients across multiple counties. Our clinicians are dedicated to both patients and each other, resulting in consistently low hospital readmission rates (under 10%) and high employee satisfaction, as recognized by Top Workplace awards. We foster an environment of support, growth, and recognition through open communication and professional development. This full-time role involves visiting patients in their homes to promote wellness and prevent re-hospitalization, with a focus on Sonoma and surrounding areas.

Requirements

Minimum of one year of Nursing Experience required; two+ years preferred.
Current and unrestricted CA RN license
Current BLS/CPR Certification
Valid CA Driver's License
High level of clinical knowledge in home health care is key
Experience working with an interdisciplinary team is required
Case Management fundamentals is required
Self-Directed
Empathetic
Critical thinker
Outstanding interpersonal skills
Leadership skills
Organized

Nice To Haves

One Year of Home Health Case Management experience is perferred
Experience supervising, mentoring Nurses is highly preferred
Experience with high acuity patients is a plus

Responsibilities

Utilize outstanding clinical skills to create, implement, and execute the overall plan of care to promote wellness and prevent re-hospitalization for patients in their homes.
Have oversight of 2 Nurses who are responsible for executing your care plan.
Conduct comprehensive patient assessments such as Start of Cares (SOCs), Evaluations, Resumption of Care, and discharge planning.
Provide assistance and teaching to patients, families, and caregivers with wound care, blood draws, tube feedings, Tracheostomy care, foley catheters, Congestive Heart Failure (CHF) management, and medication education in the patient's home.
Perform a full assessment of the patient & family upon initial visit.
Use assessment data to develop an advanced plan of care including rehabilitation.
Work with patients and family one on one to achieve improvement and/or stability.
Case manage patients care episode with interdisciplinary clinical team.
Prepare clinical notes, orders, and charting in a compliant time frame.
Collaborate with physicians and agency staff to deliver the best care possible.