Home Health Rn Case Manager Jobs in Santa Rosa, CA

Sonoma, California, United States

By The Bay Health, a non-profit established in 1975, set the standard for hospice in the U.S. by emphasizing the role of the patient in making important medical decisions. Our spectrum of home-based services now includes Skilled Home Health Care, Palliative Care, Adult Hospice Care and Pediatric Care. Our team approach strives to address practical, social, emotional and spiritual aspects of care, with the goal to maximize quality of life for our patients, caregivers and families.

Office Location: San Francisco Service Area: Sonoma County with additional coverage to Marin County Schedule: 5 days per week; 8:30 a.m.– 5:00 p.m. Compensation: $65.00 – $75.00 per hour

As a Home Health Registered Nurse (RN Case Manager), you will provide skilled, compassionate nursing care to patients in their homes — helping them recover, remain independent, and live safely in their chosen environment. You will assess patient needs, develop individualized plans of care, and collaborate closely with physicians, therapists, social workers, and other members of the interdisciplinary team to ensure high-quality outcomes and patient satisfaction. This position offers a meaningful balance of autonomy and teamwork, allowing you to practice the full scope of nursing while being supported by a dedicated, mission-driven organization.

Patient Care & Clinical Responsibilities

• Serve as the RN Case Manager for an assigned caseload of home health patients, coordinating and overseeing all aspects of care.
• Perform comprehensive initial assessments to determine the patient's skilled nursing and home care needs.
• Develop and initiate the Plan of Care (POC) and obtain physician orders for necessary services and changes.
• Provide direct skilled nursing interventions in accordance with the POC — including wound care, medication administration, IV therapy, catheter care, and disease management.
• Educate patients and caregivers on self-care, medication adherence, symptom recognition, and 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, and 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 and 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 visit 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 care 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 and 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.

By the Bay Health is proud to serve our community as an equal employment opportunity employer. Everyone is valued and welcome at BTBH. Our organization is committed to diversity, equity and continues to build a culture of inclusion by recruiting, screening, hiring and retaining any qualified individual without regard to age, race, color, ethnicity, religion, gender, gender identity or expression, sexual orientation, disability, marital status, registered domestic partner status, citizenship, physical or mental disability, legally protected medical condition, family care status, military care status, veteran status or any other consideration made unlawful by Federal, state, or local laws.