Benefits:

401(k) matching

Competitive salary

Dental insurance

Health insurance

Paid time off

Vision insurance

Job Summary

The RN Home Care Manager is responsible for conducting comprehensive initial home care assessments and developing detailed care plans that will be implemented by LVNs and PCAs. This role provides clinical leadership in the assessment, planning, implementation, and evaluation of nursing care while serving as a critical member of the Interdisciplinary Team (IDT). The position includes oversight of care delivery across multiple settings, including the PACE center, participants' homes, virtual visits, and skilled nursing facilities (SNF), with direct supervision of Personal Care Assistants (PCAs) and LVNs to ensure quality care delivery.

Essential Duties & Responsibilities

Assessment and Care Planning, conduct comprehensive initial home care assessments for all new participants, including:

• Detailed environmental safety evaluation

• Physical, psychosocial, and behavioral status assessment

• Caregiver capability and support system evaluation

• Medical equipment and supply needs assessment

• Fall risk and mobility assessments

• Standardized PACE assessment tools implementation

• Risk stratification assessment

Develop detailed, individualized care plans based on assessment findings:

• Create structured care plans using standardized templates

• Clearly delineate tasks appropriate for LVN versus PCA implementation

• Establish specific protocols for routine and complex care situations

• Define escalation pathways for changes in participant condition

• Include measurable outcomes and goals

• Conduct periodic reassessments to evaluate effectiveness of care plans

• Make necessary adjustments to care plans based on participant response and outcomes

• Maintain comprehensive documentation using approved templates and systems

Clinical Care Management

• Oversee the implementation of care plans by LVNs and PCAs

• Review and approve LVN care delivery protocols

• Monitor participant response to interventions

• Partner with medical providers to ensure care plans align with treatment goals

• Manage complex care situations requiring RN level expertise

• Provide direct care for complex procedures within RN scope of practice

• Establish and maintain clear criteria for task delegation

• Implement care plan review schedules

Leadership and Supervision

• Supervise and coordinate care delivery between LVNs and PCAs

• Provide clinical guidance and support to LVNs in care implementation

• Directly supervise PCAs, including:

• Develop and oversee schedules and assignments

• Provide ongoing training and competency evaluations

• Monitor documentation and care delivery

• Conduct performance evaluations

• Implement improvement plans as needed

• Ensure all care delivery complies with state regulations and PACE requirements

• Facilitate communication between care team members

• Develop and maintain PCA orientation program

• Conduct regular skills assessments and competency checks

Quality Assurance and Performance Improvement

• Establish and monitor quality metrics for home care services

· Care plan completion rates

· Implementation success rates

· Participant satisfaction scores

· Documentation compliance rates

· Incident and accident rates

Develop and maintain quality improvement initiatives:

• Lead quality improvement projects

• Track and analyze outcome data

• Implement corrective action plans

• Monitor effectiveness of interventions

Conduct regular audits of:

• LVN and PCA documentation

• Care plan implementation

• Medication administration

• Infection control practices

Create and maintain feedback mechanisms for:

• Participants and families

• LVNs and PCAs

• IDT members

• Care partners

Care Coordination and Education

• Lead IDT meetings regarding home care services

• Develop and provide training programs for LVNs and PCAs

• Create competency checklists

• Develop skill assessment tools

• Implement continuing education programs

• Educate participants, caregivers, and family members on care plans

• Coordinate care transitions with facility case managers

• Train care team members on participant specific needs

• Establish clear communication channels between all care team members

Education & Training

• Current California Registered Nurse (RN) license.

• Current BLS certification required.

• Minimum of 2 years' experience in ambulatory, home health, hospital or sub-acute setting preferred; equivalent

training or related experience considered.

• A minimum of one year experience working with elderly population.

Required Qualifications

• Current, unrestricted Registered Nurse (RN) license in California

• Bachelor of Science in Nursing (BSN) preferred

• Minimum of 3 years' experience in home health or community-based care

• Demonstrated experience in comprehensive assessment and care planning

Preferred Qualifications

• Previous supervisory experience required

• Current BLS/CPR certification (or obtain within 30 days of employment)

• Strong clinical acumen in complex care management

• Proof of medical clearance and current immunizations

• Valid CA driver's license, personal transportation, and required auto insurance

• Excellent documentation and care planning skills

• Strong organizational and leadership abilities

• Proficiency in electronic health record systems