Registered Nurse Case Manager

Home & Health Care Management•Sacramento, CA

5d•$43 - $53

About The Position

Home & Health Care Management provides comprehensive in-home care and case management for older adults, children, and people living with disabilities across multiple counties. The Registered Nurse Case Manager performs a variety of activities to support patients’ comfort and well-being in their homes, developing and implementing client-specific plans of care within the scope of their education, physician orders, and client input. The role serves clients enrolled in the Assisted Living Waiver (ALW), California Community Transitions (CCT), and 811 Housing programs. The position includes nursing assessments and care coordination in clients’ homes, skilled facilities, and through telehealth. The nurse collaborates with clients, families, physicians, agency social workers, caregivers, facility staff, and other care team members; documents services and changes in condition; provides teaching; and supports transitions from skilled facilities to community settings. Duties vary by program and may include skilled nursing interventions, medication management, OASIS assessments, supervision of home health aides, and ongoing assessment and care planning.

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, as well as 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.
Reliable vehicle and ability to drive to participants’ homes and HHCM 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.
If working remotely, maintain 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; identified as preferred.

Responsibilities

Work with clients in multiple settings and across various long-term care programs.
Participate in case conferences and educational activities as required.
Complete client-record documentation on the day of service and use the electronic health record appropriately.
Participate in staff meetings, in-service training, and other mandated agency activities.
Assess clients’ nursing and care needs during visits at home, in skilled facilities, and via telehealth.
Report changes in clients’ conditions to their physicians and document the reports in the clinical record.
Update required documentation according to program requirements and agency standards.
Provide patient and family teaching as needed and encourage safe, sanitary home environments.
Report at-risk clients to Adult Protective Services or Child Protective Services as required as a mandated reporter.
Perform other specific duties assigned by the supervisor.
For CCT transitional care clients, assist the agency social worker with transitions from skilled facilities to homes or other appropriate settings with supportive services.
Complete CCT assessments in MedCompass and agency electronic health records, including the initial nursing assessment and RN sections of transition plans.
Coordinate with social workers, clients, caregivers, and facility discharge planners to ensure medical supplies, equipment, medications, and post-transition medical providers are in place.
For 811 housing clients requiring skilled care, develop and implement client-specific Plans of Treatment with the client, physician, and caregiver as appropriate.
Establish treatment goals and timelines, update plans at least every two months and when needs change, and coordinate with team members, physicians, and available resources.
Ensure physician orders are in place for skilled 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.
Re-evaluate and modify treatment plans and interventions in response to client needs, preferences, responses, or physician orders.
Perform simple 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 receiving agency aide services.
Collaborate with HCBA Waiver Care Management Team members to meet 811 clients’ needs.
For ALW clients, complete initial nursing assessments to determine tier levels and ongoing assessments every six months and when care needs change.
Visit ALW clients on the caseload at least every six months and when care needs change.
Collaborate with agency social workers and develop client-specific Individual Service Plans with clients or legal representatives, social workers, and caregivers or RCFE staff as appropriate.
Update ALW Individual Service Plans every six months and when care needs change, modifying interventions in response to client needs, preferences, and responses.