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