Registered Nurse Case Manager

Home & Health Care Management is the oldest home health care agency in Northern California. Our agency specializes in delivering comprehensive in-home care and case management for older adults, children, and those living with disabilities across many counties. We use a matrix of Medi-Cal, Medicare and targeted health programs to find solutions that work for our clients.

Job Description

Home & Health Care Management is the oldest home health care agency in Northern California. Our agency specializes in delivering comprehensive in-home care and case management for older adults, children, and those living with disabilities across many counties. We use a matrix of Medi-Cal, Medicare and targeted health programs to find solutions that work for our clients.

JOB SUMMARY: Performs a wide variety of activities for the comfort and well-being of patients in their homes including the development and implementation of a client-specific Plan of Care within the confines of educational preparation, physician orders and client input. Provides services to clients who are enrolled in the Assisted Living Waiver (ALW) Program, California Community Transitions (CCT) Program and 811 Housing program

Required JOB QUALIFICATIONS AND EXPERIENCE:

1. An Associate Arts degree in nursing or a baccalaureate degree in Nursing from an accredited program.
2. One year experience working in community health setting, home health agency or in a hospital (preferred).
3. A current California Registered Nurse License
4. Skilled in operating a computer utilizing a variety of standard software (excel, word, adobe) and Electronic Health Records.
5. For individuals working remotely, must have a home office workspace that meets HIPAA requirements
6. Able to work with a multidisciplinary team.
7. Able to make face to face visits with clients where they are living
8. A current California Driver's License.
9. Current automobile insurance with agency specified limits.
10. Have a reliable vehicle.
11. Able to drive oneself to participant's homes and HHCM offices with no driving and weather limitations.
12. Produce a Department of Motor Vehicles (DMV) printout prior to being hired that meets agency requirements.
13. Current CPR certification
14. TB PPD test or alternative as determined by agency policy.

TRAVEL:


Coverage area is greater Sacramento/San Joaquin areas.

RESPONSIBILITIES:

1. Able to work with clients in multiple settings and with various long-term care programs
2. Participates in case conferences and educational activities as required.
3. Completes all documentation for the client record on day of service.
4. Utilizes the electronic health record appropriately to document information in the client record.
5. Participates in mandated agency activities including staff meetings and in-service training
6. Completes a nursing assessment and evaluates the client's nursing and care needs during visits with clients in their homes, in skilled facilities, and/or via telehealth visits.
7. Reports changes in client's conditions to the client's physician and documents these reports in the clinical record.
8. Updates required documentation per program requirements.
9. Completes all required documentation per agency standards.
10. Participates in patient and family teaching as needed.
11. Encourages a safe and sanitary environment in the client's home setting
12. Reports to Adult Protective Services/Child Protective Services for any at-risk clients as required as a Mandated Reporter.
13. Participates in other specific duties as assigned and defined by their supervisor.

For Transitional Care Clients (i.e..those clients enrolled in California Community Transitions Program - CCT) :

1. Assists the agency social worker with transitional care activities to allow clients to transition from skilled facilities to a home setting (house or apartment) with supportive services as available and appropriate (i.e. In Home Supportive Services and HCBA Waiver services), Residential Care Facility for the Elderly (RCFE) under the Assisted Living Waiver (ALW) Program or Congregate Living Health Facility (CLHF) under the Home and Community Based Alternatives Waiver (HCBA).
2. Complete required assessments for transitional care clients using MedCompass and agency Electronic Health Records:
   1. Initial nursing assessment
   2. Collaborate with the social worker to complete the Initial Transition and Care Plan (ITCP) for CCT clients
   3. Complete the RN assessment section within the Final Transition and Care Plan (FTCP) for CCT clients
3. Coordinate with agency social workers, clients, caregivers and facility discharge planners to ensure that clients have all necessary medical supplies, equipment and medications prior to transition from skilled facilities.
4. Ensure all clients have been established with post transition providers for medical care needs

For skilled care clients enrolled in the 811 housing programs:

1. When skilled care is required, develops and implements a client-specific Plan of Treatment in conjunction with the client, physician and caregiver (as appropriate.) These Plans of Treatment are based on identified client needs and:
   1. Include goals with a time framework for completion.
   2. Are developed at the initial visit and updated as changes occur, at least every 2 months.
   3. Reflect coordination and cooperation with team members, physician and utilization of available community and agency resources.
   4. Interventions are based on nursing assessment.
   5. Interventions are reflective of established clinical practice.
2. Ensure that there are physician orders for all skilled care that agency nursing staff performs, and that the orders are regularly and timely re-evaluated and updated.
3. Administers prescribed medications and treatments and will fill medication boxes and perform medication management services when needed.
4. Regularly and timely re-evaluates the Plan of Treatment. Modify or change interventions in response to patient responses, needs, requests and/or physician orders.
5. Performs simple diagnostic tests (such as taking vital signs with each skilled nursing visit, performing blood glucose monitoring and taking pulse oximeter readings.)
6. Complete required OASIS assessments every 2 months
7. Perform supervision of home health aides every 14 days for 811 clients who also have agency Home Health Aide services.
8. Collaborate with HCBA Waiver Care Management Team members to ensure all 811 client needs are met.

For clients enrolled in the Assisted Living Waiver (ALW) Program:

1. Complete an initial nursing assessment to determine tier levels for clients applying for the ALW program.
2. Complete on-going nursing assessments every six months and when changes in care needs occur.
3. Visit all ALW clients on their case load at least every 6 months and when changes in care needs occur.
4. Collaborates with agency social workers to ensure client needs are being met.
5. Develop a client-specific Plan of Care (Individual Service Plan - ISP) in conjunction with the client/legal representative, (as appropriate) program social workers, and caregivers/RCFE staff (Residential Care Facility for the Elderly) staff.
6. ISPs are developed at the initial visit, and updated every six months and when changes in care needs occur. Interventions are modified/changed in response to patient responses, needs, requests

Compensation:

Pay range is $43.00 - $53.00 / hour. Exact compensation may vary based on skills and experience.

Benefits:


We value our employees and are proud to offer competitive compensation and benefits package, which may include:

• Medical, Dental & Vision Insurance
• Company-Paid Life Insurance
• Long-Term Disability Insurance
• FSA (Medical and Dependent Care)
• Aflac
• 401(k) Retirement Plan with Company Match
• Paid Time Off (Vacation, Sick Leave & Holidays)
• Monthly phone Stipend
• Employee Assistance Program (EAP)
• Mileage Reimbursement (For Eligible Positions)
• Company Vehicles Available (For Eligible Positions)

Apply

If you have an interest in joining our amazing team, we would like to hear from you!

Click here to apply online.

You can also download the application packet located at
and fax completed applications to View phone number on click.appcast.io or mail to us at 1398 Ridgewood Dr., Chico, CA 95973, Attention: HR Department.