Nurse Case Manager

The Nurse Case Manager is responsible for providing direct care, oversight and training for all paramedical services performed by Home Care Providers for the frail, elderly, and people with disabilities served by Homebridge’s contract mode services.

The Nurse Case Manager’s primary role is to train Home Care Providers on  how to deliver paramedical services to their assigned clients.  The Nurse Case Manager will monitor the health and progress of clients with paramedical tasks and will ensure that the care provided is of high quality and in compliance with Homebridge’s contract provisions, policies and procedures, and are within the scope of the agency’s resources and mission.

Essential Job Functions

  • Maintains a caseload of 50-85 clients with paramedical and complex personal care needs
  • Receives client referrals from Homebridge staff for paramedical and medication assistance, training and/or education. 
  • Conducts and documents comprehensive in-home health assessments based on Paramedical Order from the County or hospital discharge.  Assessment includes identifiying clients psychosocial, physical and environmental needs
  • Writes Paramedical Plan notes in a client focused manner to best meet client health and safety needs
  • Trains and monitors quality of each Home Care Provider providing paramedical tasks according to physician instructions.  This includes assisting Home Care Providers with creative strategies and interventions to encourage complex clients to accept services. 
  • Identifies, educates and recommends solutions to potential safety hazards in the client’s home.  This includes but is not limited to coordinating physician referrals for P.T./O.T. assessments to evaluate for durable medical equipment and assistive devices
  • Establishes and maintains a professional relationship with clients and their support network, treating them with respect and dignity. Provides crisis intervention, advocacy, problem solving and therapeutic interventions
  • Identifies appropriate community services and resources, including connection to Medicare, Medi-Cal, and other entitlement programs
  • Establishes and maintains professional and collaborative relationships with others in the community including the client’s physician(s), other health care and social service workers, while maintaining confidentiality
  • Works as a team with other Homebridge staff to provide comprehensive support to clients, including providing trainings on working with medically compromised clients
  • Actively incorporates the ethical standards of the American Nurse Association in all aspects of interactions with others
  • Complies with Welfare & Institutions Code (W&I) section 15630(a) California law (mandated reporter) requiring Homebridge employees to report known or suspected abuse of dependent adults or elder, immediately by telephone or as soon as practically possible, and by written report with two (2) working days (W&I) section 15630(b)
  • Provides backup paramedical training to San Mateo region, when needed
  • Attends continuing education classes and/or in-service trainings to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the agency’s client population
  • Utilizes supervision appropriately; maintains open lines of communication with supervisor; updates supervisor on caseload activity; seeks advice in a timely manner
  • Maintains required client forms and a clear, concise, and consistent system of charting to enable continuity of care according to State and Federal regulations
  • Adheres to Homebridge’s safety policies and procedures to assure personal safety on each home visit

Knowledge, Skills, and Abilities

  • Demonstrates understanding of normal aging, health and psychosocial needs of the frail elderly and people with disabilities, including family systems, substance abuse, dementia, personality disorder, etc.
  • Possesses strong skills in nursing, rehabilitation and case management of older adults and people with disabilities
  • Must have strong communication skills and be able to engage and train para professional staff providing care to complex clients in home settings
  • Possesses strong knowledge of Medicare, Medi-Cal, and other entitlement programs. 
  • Demonstrates knowledge of community resources available for target population
  • Proficient in use of Microsoft Office and able to quickly master use of proprietary software
  • Must take initiative, and have the ability to think independently as well as work in a team and have excellent interpersonal skills
  • Must be creative, flexible and well organized with good planning abilities to meet deadlines
  • Must have the ability to clearly and effectively present information, oral and written, and to respond to questions from a variety of individuals including but not limited to: co-workers, clients and the general public
  • Must have the ability to critically analyze, address and solve complex problems.  Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
  • Bilingual in Spanish, Cantonese, Tagalog, or Russian may be required

Education and Experience  

Licensed Vocational Nurse (LVN) required. RN preferred. Valid current license to practice nursing in the State of California and current CPR and First Aid certificate required. Two years’ experience, two of which are in public health, community social service or home health agency performing case assessments, intervention and developing care plans required.    Acute care and geriatric experience preferred. Prefer experience common in a clinic setting, such as wound care, urinary catheterizations, etc.  Ability to work flexibly within a multidisciplinary team and with a multicultural population. Computer literacy required. Bilingual preferred (Spanish, Cantonese preferred).

Work Environment

This position is partially sedentary, working at a desk in a temperature controlled office, in modular office space or an individual office. The noise level in the work environment is usually moderate.  Frequent Travel:  must be able to travel on foot, via public transportation or personal vehicle to all parts of San Francisco and San Mateo occasionally for performance of job duties. May occasionally be exposed to outside weather conditions while traveling to clients. Some exposure to physical risk. Frequent exposure to client apartments, rooms, homes and other venues so that services can be provided. May include contact with clients with mental health and/or personal hygiene issues.  

Physical Demands

The physical demands described here are representative of those that must be met by employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. While performing the duties of the job, the employee is regularly required to talk or hear. The employee is frequently required to sit for extended periods of time at a desk or computer workstation. The employee is frequently require to stand, walk, sit, use hands to finger, handle, or feel, reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, or crouch. The employee may occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.

How to apply

Please send cover letter and resume to jobs@homebridgeca.org with “Nurse Case Manager” as the subject. Fax: 415-659-5358.

Homebridge is an equal opportunity, affirmative action employer committed to maintaining a non-discriminatory, diverse work environment.