RN Case Manager - Full Time - Sonoma County

Territory: Sonoma County.

Job Description Summary

The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Essential Job Functions/Responsibilities

Patient Care:

1. Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es)
2. Regularly re-evaluates patient nursing needs.
3. Initiates the plan of care and makes necessary revisions as patient status and needs change.
4. Uses health assessment data to determine nursing diagnosis.
5. Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
6. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. Provides direct patient care as defined in the State Nurse Practice Act.
7. Counsels the patient and family in meeting nursing and related needs.
8. Provides health care instructions to the patient as appropriate per assessment and plan of care.
9. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
10. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Communication:

1. Prepares clinical notes and updates the primary physician when necessary and at least every 60 days.
2. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
3. Communicates with community health related persons to coordinate the care plan

Additional Duties:

1. Participates in on-call duties as defined by the on-call policy.
2. Ensures that arrangements for equipment and other necessary items and services are available.
3. Instructs, supervises, and evaluates home health aide care provided every two (2) weeks.
4. Must adhere to the company attendance and reliability guidelines, which are an essential function of the job to ensure quality, and consistent patient care.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbent(s) of this job. The incumbent(s) may be requested to perform job related tasks other than those stated in the description.

Position Qualifications

• Graduate of an accredited school of nursing.
• Minimum of 2 years licensed experience (California).
• Current licensure in state and CPR certification.
• Bachelor’s degree, with one (1) year of home health care experience preferred.
• Management experience not required. Responsible for supervising home health aides.
• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
• Prolonged or considerable walking or standing. Able to lift, position or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills.
• Must possess a valid California Driver’s License with automobile that is in good working order and insured in accordance with the organization requirements.

Physical Requirements

1. The ability to sit occasionally for 1-3 hours.
2. The ability to frequently stand for 3-6 hours.
3. The ability to occasionally drive/ operate foot control for 1-3 hours.
4. The ability to walk intermittently on level and or unlevel surface for less than 1 hour.
5. The ability to intermittently bend or climb for less than 1 hour.
6. The ability to occasionally twist, kneel, crouch and crawl for 1-3 hours.
7. The ability to lift 50 pounds frequently for 3-6 hours.
8. The ability to lift greater than 50 pounds occasionally for 1-3 hours.
9. The ability to carry up to 50 pounds frequently for 3-6 hours.
10. The ability to carry greater than 50 pounds occasionally for 1-3 hours.
11. The ability to push up to 50 pounds frequently for 3-6 hours.
12. The ability to push greater than 50 pounds occasionally for 1-3 hours.
13. The ability to pull up to 50 pounds frequently for 3-6 hours.