RN Case Manager

About the role

Petaluma Health Center provides high-quality, patient-centered care in Southern Sonoma County and West Marin. Its RN Case Manager coordinates care for diverse, high-risk and complex patients moving from acute care settings, with a focus on geriatric patients, vulnerable populations and those with complex health needs.

Key responsibilities

• Oversee and facilitate the transition of care for high-risk patients from acute settings to home or community resources
• Collaborate with patients, families and the interdisciplinary team to build individualized care plans
• Assess medication regimens, educate patients and families on adherence, and coordinate with pharmacy; perform medication reviews and adjustments per protocol with provider support
• Process medication refills according to protocol
• Use PHC-approved materials to educate patients and families on diagnosis, treatment, medications, disease management and self-management
• Conduct phone triage assessments and advise adult and geriatric patients, following PHC triage protocol
• Work with providers, care transition coordinators, team nurses, behavioral health professionals and community agencies
• Take part in quality improvement efforts to reduce hospital readmissions
• Maintain accurate documentation of care plans, interactions and outcomes in the electronic medical record, in line with Joint Commission standards and PHC policies
• Train the care transition coordinator and staff, mentor new staff and students, and conduct annual competency evaluations

Required profile

• Active California RN license in good standing
• Associate of Science in Nursing (ASN/ADN) or equivalent accredited nursing education to obtain a California RN license; BSN preferred
• At least one year of case management nursing experience preferred
• Valid California driver's license
• Bilingual English and Spanish (written and spoken) preferred, assessed at Advanced or Intermediate level

Required skills

• Current Basic Life Support (BLS) certificate
• Ability to meet PHC's credentialing and privileging requirements

What we offer

• 21 days of paid time off and 10 observed holidays
• Medical, dental and vision insurance, with the entire medical deductible covered
• 30 chiropractor and acupuncture visits per year with Kaiser and WHA plans
• 401K matching after 1 year, flexible spending account and dependent care FSA
• Life insurance, long-term disability and employee assistance program included at no cost
• Gym membership discounts and reimbursement for RN re-licensure fees and continuing education units