RN Case Manager
Petaluma Health Center
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.
Job description
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.
Requirements
- 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
- 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
- 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
- Bilingual in English and Spanish, both written and verbal preferred
Benefits
- 21 Days PTO
- 10 Observed Holidays
- RN Re-licensure Reimbursement
- Continuing Education Units
- Medical Insurance
- Chiropractor & Acupuncture Visits
- Dental Insurance
- Vision Insurance
- Gym Membership Discounts
- 401(k) Matching
- Flexible Spending Account
- Dependent Care FSA
- Life Insurance
- Long Term Disability
- Employee Assistance Program
Company overview
Petaluma Health Center is a comprehensive community healthcare provider serving the Petaluma region in California. As a community health center, it offers a wide range of medical services to meet the diverse healthcare needs of local residents. The organization focuses on providing accessible, high-quality healthcare services to all members of the community, regardless of their ability to pay. Petaluma Health Center typically offers primary care services, preventive medicine, chronic disease management, and various specialty services to ensure comprehensive patient care. Community health centers like Petaluma Health Center play a vital role in the healthcare ecosystem by addressing healthcare disparities and improving health outcomes for underserved populations. These centers often participate in federal programs to provide sliding-scale fees and accept various insurance plans to maximize accessibility. The organization's mission likely centers on promoting health equity and delivering patient-centered care that addresses both medical and social determinants of health within the Petaluma community.