RN Case Manager

The Petaluma Health Center's mission is to provide high quality health care with access for all in Southern Sonoma County & West Marin. We pride ourselves on our Patient-Centered care while maintaining an engaging environment for our staff. The Center accomplishes this mission through collaborative, innovative programs, services and referral resources that meet the economic needs of the entire community.

Full Time Employee Benefits

• 21 Days of Paid Time Off
• 10 Observed Holidays
• Reimbursement for RN re-licensure Fee
• Reimbursement of 20 Continuing Education Units for RN re-licensure
• Medical Insurance (Entire deductible paid by us!)
• 30 Chiropractor and Acupuncture visits per year included with enrollment in our health insurance plans (Kaiser and WHA)
• Dental Insurance

Vision Insurance

• Gym Membership Discounts at Synergy Health Club and 24-Hour Fitness!
• 401K Matching after 1 year of employment
• Flexible Spending Account, Dependent Care FSA
• Life Insurance (included at no cost to the employee)
• Long Term Disability (included at no cost to the employee)
• Employee Assistance Program (included at no cost to the employee)

Summary: The Case Manager Registered Nurse is responsible for coordinating care for diverse, high-risk, and complex patients transitioning from acute care settings. The Case Manager RN role ensures that clients receive patient-centered care to achieve improved health outcomes, with a particular focus on geriatric patients, vulnerable populations, and those with complex health needs.

Areas of Responsibility

RN Case Manager Duties

Patient Care& Education

Oversee and facilitate the transition of care for high-risk patients, ensuring continuity and quality from acute settings to home or community resources.

Collaborate with patients, families, and interdisciplinary team members to develop individualized care plans for complex and high risk patients.

Assess patients’ medication regimens, provide education on medication adherence, and coordinate with pharmacy services to ensure safe and effective medication use.

• Perform medication reviews and adjustments according to protocol, with support of provider
• Processes medication refills in accordance with established protocols

Utilize PHC approved educational materials to provide comprehensive education to patients and their families regarding diagnoses, treatment plans, medications, disease management, self-management techniques, wellness, and related processes, under the direction of licensed clinical staff.

Conduct comprehensive phone triage assessments and provide advice for adult and geriatric patients to address concerns, evaluate needs, and implement appropriate interventions under the direction of licensed clinical staff, per PHC triage protocol

Work closely with healthcare providers, care transition coordinator, team nurses, behavioral health professionals, and community agencies to enhance care delivery and improve patient outcomes.

Participate in quality improvement initiatives aimed at reducing hospital readmissions and improving healthcare outcomes and access to care for high-risk populations.

Documentation & Work Environment

• Maintain accurate documentation of patient interactions, care plans, and outcomes in compliance with Joint Commission standards and PHC policies
• Document patient care provided in visit in a timely manner in the electronic medical record
• Document phone triage assessments appropriately in the electronic medical record
• Document and reports malfunction of PHC equipment
• Maintain a clean, orderly and functional work environment
• Promote continuous improvement of workplace safety and environmental practices

Training

Conduct annual competencies to demonstrate proficiency in patient care and evaluate colleagues to ensure compliance with case management standards.

Provide guidance and training to the care transition coordinator and designated staff on case management best practices and processes.

Mentor and orient new staff, students and other team members

Education/Experience

Associate of Science in Nursing (ASN/ADN) or sufficient nursing education from an accredited nursing school to obtain a California Registered Nurse (RN) license required

Bachelor of Science in Nursing (BSN) preferred

At least one year of experience in case management nursing within a healthcare setting focused on high-risk populations preferred

Licenses and Certifications

• Active State of California Registered Nurse (RN) License in good standing required
• Valid State of California Driver’ s License (DL) in good standing required
• Current Basic Life Support (BLS) certificate required
• Candidate must be able to successfully meet PHC’s credentialing and privileging requirements

Language Skills: Bilingual in English and Spanish, both written and verbal preferred. Assessed by language proficiency test as Advanced or Intermediate level.