Registered Nurse Case Manager

Home & Health Care Management•Sacramento, CA

About The Position

Home & Health Care Management provides in-home care and case management for older adults, children, and people living with disabilities throughout Northern California. The Registered Nurse Case Manager performs activities that support patients’ comfort and well-being in their homes and develops and implements client-specific plans of care consistent with the nurse’s education, physician orders, and client input. The position serves clients enrolled in the Assisted Living Waiver (ALW), California Community Transitions (CCT), and 811 Housing programs. The coverage area includes the greater Sacramento and San Joaquin areas. The role includes client visits in homes and skilled facilities, as well as telehealth visits. For CCT clients, the nurse supports transitions from skilled facilities to homes or other appropriate settings, completes required assessments and transition-plan documentation, and coordinates with social workers, caregivers, facility discharge planners, and providers. For 811 Housing clients requiring skilled care, the nurse develops and updates plans of treatment, administers prescribed medications and treatments, performs basic diagnostic tests, completes OASIS assessments, supervises home health aides as required, and collaborates with the HCBA Waiver Care Management Team. For ALW clients, the nurse assesses eligibility and ongoing care needs, visits clients at least every six months and as needs change, and develops and updates Individual Service Plans with clients, representatives, social workers, and caregivers or facility staff. The listed pay range is $43.00–$53.00 per hour; exact compensation may vary based on skills and experience. Benefits may include medical, dental, and vision insurance; company-paid life insurance; long-term disability insurance; FSA; Aflac; a 401(k) retirement plan with company match; paid time off; a monthly phone stipend; an Employee Assistance Program; mileage reimbursement for eligible positions; and company vehicles for eligible positions.

Requirements

Associate Arts degree in nursing or a baccalaureate degree in Nursing from an accredited program.
Current California Registered Nurse license.
Skilled in operating a computer and standard software, including Excel, Word, and Adobe, and electronic health records.
Able to work with a multidisciplinary team.
Able to make face-to-face visits with clients where they live.
Current California Driver’s License.
Current automobile insurance with agency-specified limits and a reliable vehicle.
Able to drive oneself to participant homes and agency offices without driving or weather limitations.
Provide a Department of Motor Vehicles printout before hire that meets agency requirements.
Current CPR certification.
TB PPD test or alternative as determined by agency policy.
For remote work, have a home-office workspace that meets HIPAA requirements.

Nice To Haves

One year of experience working in a community health setting, home health agency, or hospital (preferred).

Responsibilities

Work with clients in multiple settings and across various long-term care programs.
Participate in case conferences, educational activities, staff meetings, and in-service training as required.
Complete client-record documentation on the day of service and use the electronic health record appropriately.
Conduct nursing assessments and evaluate clients’ nursing and care needs during visits at home, in skilled facilities, or via telehealth.
Report changes in client conditions to physicians and document reports in the clinical record.
Update required documentation and complete documentation in accordance with program requirements and agency standards.
Provide patient and family education as needed and encourage a safe, sanitary home environment.
Report at-risk clients to Adult Protective Services or Child Protective Services as required of a mandated reporter.
Assist the agency social worker with CCT transitional-care activities, including transitions from skilled facilities to home or other appropriate settings.
Complete required CCT assessments in MedCompass and agency electronic health records, including initial nursing assessments and RN sections of transition plans.
Coordinate with social workers, clients, caregivers, and facility discharge planners to arrange necessary medical supplies, equipment, medications, and post-transition medical providers.
For 811 Housing clients requiring skilled care, develop and implement client-specific Plans of Treatment with the client, physician, and caregiver as appropriate; establish goals and time frames; and update plans at least every two months and when needs change.
Ensure physician orders are in place for skilled nursing care and are re-evaluated and updated in a timely manner.
Administer prescribed medications and treatments, fill medication boxes, and provide medication management when needed.
Modify nursing interventions in response to client needs, requests, responses, and physician orders.
Perform basic diagnostic tests, including vital signs, blood glucose monitoring, and pulse oximeter readings.
Complete required OASIS assessments every two months.
Supervise home health aides every 14 days for 811 clients who receive agency home health aide services.
Collaborate with HCBA Waiver Care Management Team members to address 811 client needs.
For ALW clients, complete initial nursing assessments to determine program tier levels and ongoing assessments every six months or when care needs change.
Visit assigned ALW clients at least every six months and when care needs change.
Collaborate with agency social workers to ensure ALW client needs are met.
Develop and update client-specific Individual Service Plans with clients or legal representatives, social workers, and caregivers or RCFE staff at initial visits, every six months, and when care needs change.
Perform other specific duties as assigned and defined by the supervisor.