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.

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

• 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

• 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.