Home Health RN

By the Bay Health; Sonoma (CA); On-site; USD 8,954,000 - 10,332,000; Full time

Benefits offered by this job

Competitive hourly pay

Mileage reimbursement

Medical, dental, and vision insurance

Retirement savings plan with employer

Paid time off and holidays

Professional development

Job summary

By The Bay Health in San Francisco is seeking an experienced Home Health RN Case Manager to deliver skilled nursing in patients’ homes. You’ll assess needs, develop care plans, and collaborate with physicians, therapists, social workers, and the interdisciplinary team to improve quality of life and patient satisfaction.

This role offers autonomy within a mission-driven nonprofit, a stable schedule, and competitive hourly pay with mileage reimbursement, benefits, and professional development.

Qualifications

• BSN degree preferred; Associate degree accepted with equivalent experience.
• Minimum of one year experience as a Registered Nurse; home health or acute care experience preferred.
• Knowledge of OASIS documentation and CMS home health regulations is a plus.

Responsibilities

• Serve as the RN Case Manager for an assigned home health caseload.
• 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.
• Collaborate with interdisciplinary team members to ensure integrated, patient-centered care.
• Communicate with physicians, patients, and families to promote understanding of the care plan.
• Coordinate patient discharges and transitions of care, ensuring continuity and safety.
• Participate in regular case conferences and team meetings to review progress.

Skills

RN Case Manager

Wound care

Medication administration

IV therapy

CMS OASIS

Home health care

Team collaboration

Patient education

Education

BSN preferred

Associates degree with equivalent experience

Tools

EMR documentation

CMS guidelines

Job description

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: 5days per week; 8:30 a.m.– 5:00 p.m.
Compensation: $65.00 – $75.00 per hour

Position Summary

As a Home Health Registered Nurse (RN Case Manager), you will provide skilled, compassionatenursing care to patients in their homes — helping them recover, remain independent, and live safely intheir chosen environment. You will assess patient needs, develop individualized plans of care, andcollaborate closely with physicians, therapists, social workers, and other members of theinterdisciplinary team to ensure high-quality outcomes and patient satisfaction. This position offers ameaningful balance of autonomy and teamwork, allowing you to practice the full scope of nursing whilebeing 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 andoverseeing all aspects of care.
• Perform comprehensive initial assessments to determine the patient’s skilled nursing and home careneeds.
• Develop and initiate the Plan of Care (POC) and obtain physician orders for necessary services andchanges.
• 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, andemergency 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, andspeech therapists, medical social workers, and home health aides — to ensure integrated,
  patient-centered care.
• Communicate effectively with physicians, patients, and families to promote understanding andadherence 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 visitnotes.
• 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 careexperience 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 andpersonal 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.

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