Registered Nurse Case Manager

Registered Nurse Case Manager - Full Time

Sonoma, CA 95476, USA

Posted Friday, January 2, 2026 at 5:00 AM

Req# 537

Registered Nurse Case Manager - Home Health - Full Time - Sonoma/Napa

The Registered Nurse Case Manager plans, organizes and directs care 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.

• Completes an initial, comprehensive, and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
• Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act.
• Assesses and evaluates patient’s status by writing and initiating plan of care.
• Writing and initiating plan of care
• Regularly re-evaluating patient and family/caregiver needs
• Participating in revising the plan of care as necessary
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self‑sufficiency and optional comfort care.
• Maintain current documentation on EMR system according to organization policies/procedures and applicable laws/regulations.
• The RN Case Manager, when assigned by the Clinical Manager/DPCS, assumes responsibility to coordinate patient care for an assigned case load.
• The Admission RN may act as Case Manager when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate patient care for assigned caseload.
• The RN Case Manager may act as an Admission Nurse when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate with intake, program staff and management to complete a patient initial admission/assessment with plan of care.

• Completes, maintains, and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Teaches the patient and family/caregiver self‑care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
• Provides and maintains a safe environment for the patient.
• Assists the patient and family/caregiver and other team members in providing continuity of care.
• Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
• Attends interdisciplinary group meetings.

• Participates in on‑call duties as defined by the on‑call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Supervises ancillary personnel and delegates responsibilities when required.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and Inservice classes.
• F…