RN Care Manager

Health•Sacramento, CA

11d•$49 - $61

About The Position

At Habitat Health, we envision a world where older adults experience an independent and joyful aging journey in the comfort of their homes, enabled by access to comprehensive health care. Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with our leading healthcare partners, including Kaiser Permanente. Habitat Health offers a fully integrated experience that brings more good days and a sense of belonging to participants and their caregivers. We build engaged, fulfilled care teams to deliver personalized care in our centers and in the home. And we support our partners with scalable solutions to meet the health care needs and costs of aging populations. Habitat Health is growing, and we’re looking for new team members who wish to join our mission of redefining aging in place. To learn more, visit https://www.habitathealth.com . Role Scope : In this role, you will be responsible for the management and delivery of direct nursing care to our participants in a variety of settings including, but not limited to, the clinic, adult day center, participant’s home, virtually, and SNF. You will serve as a critical member of the Interdisciplinary Team (IDT) and work collaboratively to complete assessments and drive forward participant care plans.

Requirements

Graduate of an accredited school of nursing; Bachelor of Science (BSN) preferred.
Unencumbered Registered Nurse (RN) license required.
Minimum 2 years of experience clinically caring for medically complex or older adults’ population.
Active listening and conflict management skills
Adapts quickly to multiple clinical settings.
Strong clinical acumen in providing clinical interventions to complex participants.
Demonstrates experience in wound care, IVs, phlebotomy, colostomy/ileostomy care, etc.
Proof of medical clearance for communicable diseases, including a TB test.
Proof of all immunizations are up to date.
Proof of current CPR/BLS certification required or requirement to obtain within 30 days of employment.
Proof of valid CA driver’s license, personal transportation, good driving record and auto insurance as required by State law.

Nice To Haves

Alzheimer’s certification is preferred.
Home Health Care Nurse certification
Bilingual: Spanish/Mandarin/Cantonese preferred.
A state issued driver’s license, personal transportation, and auto insurance as required by law.

Responsibilities

Contribute to a center experience that Participants want to spend time in, a team culture that cares and creates joy, and an environment where all participants and team members belong.
Continue to raise the bar. Constructively seek and share feedback and help us implement changes in order to improve clinical outcomes and experience for participants.
Exhibit and honor Habitat’s Values.
Participate in Interdisciplinary Team (IDT) meetings by contributing insights from assessments, care plan recommendations, and care coordination in a collaborative spirit.
Conducts face-to-face nursing assessments that are inclusive of physical, psychosocial, and behavioral statuses in various settings, primarily in the Habitat center but also in–home.
In partnership with a medical provider, delivers personalized care for a panel of participants based on care plans.
Delivers and documents nursing interventions as agreed upon in participant's care plans, promptly and accurately responding to physician orders, and correctly administering medications and therapeutic interventions.
Triages in the outpatient setting, which includes independently initiating therapies within scope of practice and collaboratively working with a medical provider to escalate care as needed.
Provides case management during transitions of care and proactively communicates with hospital and long-term care facility case managers for care coordination.
Educates participants, caregivers including family members, and team members on how to personalize and carry out care plans.
Aid with all wound care (including complex wounds), IV (hydration, therapies), and any additional procedures within RN scope of practice identified to meet evolving participant needs.
Provide clinical support to Medical Assistants performing procedures in the clinic as needed.
Remotely takes after-hour calls that are triaged on a rotating schedule.
Performs related duties as assigned.