Office Location: Sonoma, CA
Service Area: Sonoma County
Schedule: Part-time, 3 days per week; 8:30 a.m.- 5:00 p.m.
Compensation: $65.00 - $75.00 per hour + additional language differential if bi-lingual in Spanish
Position Summary
As a Home Health Registered Nurse (RN Case Manager), you will provide skilled, compassionateย nursing care to patients in their homes - helping them recover, remain independent, and live safely inย their chosen environment. You will assess patient needs, develop individualized plans of care, andย collaborate closely with physicians, therapists, social workers, and other members of theย interdisciplinary team to ensure high-quality outcomes and patient satisfaction. This position offers aย meaningful balance of autonomy and teamwork, allowing you to practice the full scope of nursing whileย being supported by a dedicated, mission-driven organization.
Essential Duties and Responsibilities:
Patient Care & Clinical Responsibilities
- Serve as the RN Case Manager for an assigned caseload of home health patients, coordinating andย overseeing all aspects of care.
- Perform comprehensive initial assessments to determine the patient's skilled nursing and home careย needs.
- Develop and initiate the Plan of Care (POC) and obtain physician orders for necessary services andย changes.
- Provide direct skilled nursing interventions in accordance with the POC - including wound care,ย medication administration, IV therapy, catheter care, and disease management.
- Educate patients and caregivers on self-care, medication adherence, symptom recognition, andย emergency response.
- Regularly evaluate and revise the POC as patient conditions and needs change.
Care Coordination:
- Collaborate with members of the interdisciplinary team - including physical, occupational, andย speech therapists, medical social workers, and home health aides - to ensure integrated,
patient-centered care. - Communicate effectively with physicians, patients, and families to promote understanding andย adherence to the care plan.
- Coordinate patient discharges and transitions of care, ensuring continuity and safety.
- Participate in regular case conferences and team meetings to review patient progress and update
goals.
Documentation & Compliance
- Complete timely and accurate clinical documentation within the electronic medical record (EMR).
- Ensure all documentation meets Medicare, state, and agency standards, including OASIS and visitย notes.
- Maintain compliance with infection control, patient safety, and regulatory requirements.
Education/Experience:
- BSN degree preferred (Associate degree accepted with equivalent experience).
- Minimum of one (1) year experience as a Registered Nurse required; home health or acute careย experience preferred.
- Knowledge of OASIS documentation and CMS home health regulations is a plus.
Certificates, Licenses, Registrations:
- Current license as a Registered Nurse in the State of California.
- Current license as a Public Health Nurse (PHN) in the State of California preferred.
- BLS certification required
Why You'll Love Working With Us
At By the Bay Health, you'll be part of a collaborative team that values your professional expertise andย personal well-being. We offer:
- Competitive hourly pay and predictable schedules
- Mileage reimbursement and paid drive time
- Comprehensive medical, dental, and vision insurance
- Retirement savings plan with employer match
- Generous paid time off and holidays
- Supportive interdisciplinary team culture
- Thorough orientation and ongoing professional development
- The satisfaction of working for a mission-driven nonprofit that truly values patient and family-centered
care
Bring your compassion and clinical skills to a nonprofit organization that has served the Bay Area for 50 years.
Apply today to join By the Bay Health - where your care makes a difference every day.