Sourcewise provides adults and their caregivers the tools and services they need to effectively navigate their health and life options. Through a comprehensive network of resources, Sourcewise strives to educate, prepare, support, and advocate for all adults, their families, and their caregivers within Santa Clara County.

The Multipurpose Senior Services Program (MSSP) is a program of the State of California that aims to prevent or delay nursing home placement of low income, frail clients who are 60 years of age or older. The RN Care Manager will conduct comprehensive health assessments for incoming and current clients of the MSSP program.

Work Schedule: Monday through Friday, 8:00 AM to 5:00 PM (40 hours per week). Some flexibility may be required based on client needs.

Work Location: Sourcewise, 3100 De La Cruz Blvd., Suite 310, Santa Clara, CA 95054. This position requires field work including home visits within Santa Clara County.

POSITION SUMMARY

The RN Care Manager performs comprehensive care management duties including health assessments, care plan development, service coordination, and ongoing monitoring of health status for MSSP participants. This position works collaboratively with an interdisciplinary team of social workers and other professionals to ensure delivery of quality services that support participants' independence and well-being. The RN Care Manager maintains complete and accurate documentation in compliance with state and federal regulations.

Clinical Assessment and Care Planning:

• Complete comprehensive health assessments, reassessments, and recertifications for program participants through home visits or telephonically as appropriate
• In collaboration with the Social Work Care Manager, develop and update individualized care plans based on client assessments and needs
• Certify level of care for program participants in accordance with state regulations
• Make accurate assessments of participants' mental and physical health status and functional abilities

Care Coordination and Service Management:

• Arrange and/or purchase services as outlined in care plans
• Monitor client status and services through regular monthly phone contact and quarterly home visits (or as clinically indicated)
• Identify and address problems in a timely manner, adjusting care plans as needed
• Provide health promotion coaching and education to participants and their families
• Connect participants with available community resources and health care services

Documentation and Compliance:

• Develop, maintain, and update care management charts and files in accordance with program requirements
• Maintain accurate and up-to-date records using Office 365 and other electronic documentation systems
• Maintain strict confidentiality of participant information in compliance with HIPAA and other applicable regulations

Collaboration and Communication:

• Participate actively in interdisciplinary care planning conferences
• Present nursing perspective in collaborative work with social workers and other team members
• Establish and maintain effective working relationships with participants, families, service providers, and team members
• Utilize effective oral and written communication skills in all professional interactions
• Relate effectively to the needs of culturally diverse, low-income, frail seniors and their families

Required:

• Current, active, and unrestricted Registered Nurse (RN) license issued by the California Board of Registered Nursing (BRN)
• Minimum of one (1) year of clinical nursing experience in a healthcare setting
• Valid California Driver's License with a clean driving record and ability to travel locally for home visits
• Reliable personal vehicle with current automobile insurance meeting state minimum requirement

Preferred:

• Experience in geriatric nursing, home health, case management, or community health settings
• Knowledge of Medi-Cal, Medicare, and other public benefit programs
• Bilingual skills (Spanish, Vietnamese, Mandarin, or other languages commonly spoken in Santa Clara County)

Knowledge of:

• Components and principles of care management for frail elderly populations
• Health care assessment, evaluation, and documentation practices
• Available community resources for seniors and individuals with disabilities
• Health promotion and patient education strategies
• Client interviewing techniques and therapeutic communication

Ability to:

• Make accurate assessments of participants' physical and mental health status
• Exercise sound clinical judgment and problem-solving skills
• Work independently while also functioning effectively as part of an interdisciplinary team
• Manage multiple priorities and maintain attention to detail
• Utilize Microsoft Office 365 and learn additional technical tools and electronic health record systems
• Communicate effectively both orally and in writing with diverse audiences
• Demonstrate cultural sensitivity and work effectively with individuals from diverse backgrounds

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands:

• Ability to sit for extended periods while conducting assessments, documentation, and computer work
• Ability to stand, walk, bend, and reach during home visits and client interactions
• Occasionally lift and carry up to 10 pounds (such as medical equipment or documentation materials)
• Frequent use of hands and fingers for computer keyboard operation, writing, and handling documents
• Visual acuity to read documents, computer screens, and conduct assessments
• Hearing ability to communicate effectively in person and by telephone

Work Environment:

• Office environment with standard lighting, temperature control, and noise levels
• Regular travel throughout Santa Clara County to conduct home visits in diverse residential settings
• Exposure to various home environments which may include stairs, pets, second-hand smoke, or other conditions
• Operation of personal vehicle in various weather and traffic conditions

Job Type: Full-time

Pay: $81,000.00 - $83,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience:

• working with older adults: 1 year (Preferred)

License/Certification:

• RN License (Required)

Ability to Commute:

• Santa Clara, CA 95054 (Preferred)

Work Location: In person