Registered Nurse (RN) – Chronic Care Management at Snowline Health

Description

Your Passion: Registered Nurse (RN) – Chronic Care Management

Who We Are:

Snowline is a non-profit organization serving the western slope of El Dorado County and the Greater Sacramento Region. For over 45 years, we’ve remained rooted in the community—partnering with local organizations to deliver personalized, compassionate care to seniors and families. Grounded in the values of teamwork, service, contribution, and excellence, Snowline Health is committed to honoring each individual’s journey with dignity and respect. Our collaborative, trauma-informed team culture supports both patient and staff well-being, and we continually invest in professional growth and quality outcomes.

Position: Registered Nurse-Registered Nurse (RN) – Chronic Care Management 

The RN for Snowline ElderCare specializes in Chronic Care Management (CCM) and plays a vital role in supporting elderly patients with multiple chronic diseases through personalized care coordination and health advocacy. This home-based and hybrid position combines remote work with in-person visits to Assisted Living Units (ALUs) and community settings. The ideal candidate will excel in fostering trust with patients and their caregivers, providing education, and ensuring patients receive the right care, from the right provider, at the right time.

Why Choose Us:

• Wellness-Centered Benefits: Medical, dental, vision, life insurance, and 401k with employer match
• Generous Time Off: Includes vacation, sick leave, and holiday pay
• Professional Development: Snowline Scholars Program supports RNs seeking continuing education
• Flexible Scheduling: Empowering autonomy and work-life balance
• Positive Culture: Recognition, celebration, and trauma-informed leadership
• Employee Assistance Program: Providing confidential support for life and work stressors
• Market-Competitive Compensation: Regular salary benchmarking reflects our commitment to fair and competitive pay (Salary Range $48–$61 per hour)
   

Responsibilities:

Patient Engagement & Assessment

• Conduct comprehensive patient assessments via home visits and telephonic outreach
• Identify risks, patient goals, and barriers to self-care
• Enroll and validate patients for Chronic Care Management or other programs
   

Care Planning & Coordination

• Develop personalized care plans in collaboration with patients and providers
• Monitor adherence and update care plans as needed
• Support transitions of care post-hospital discharge to prevent readmissions
   

Education & Empowerment

• Deliver disease-specific education (e.g., CHF, diabetes, COPD)
• Help patients and caregivers navigate the healthcare system
• Support behavior change using motivational interviewing strategies
   

Documentation & Compliance

• Maintain timely, accurate documentation in EHR
• Ensure compliance with CMS billing standards for CCM, PCM, and TCM programs
• Monitor patient outcomes and leverage reporting tools to track progress
   

Collaboration & Communication

• Attend care team meetings and huddles
• Serve as a liaison for patients, families, and providers
• Coordinate referrals to specialists or community resources
   

Requirements

Requirements:

• Active RN license in California
• 3–5 years of nursing experience in chronic care, home health, or primary care (geriatric experience preferred)
• Strong assessment, critical thinking, and communication skills 
• Proficiency with EHRs and virtual care platforms 
• Comfortable with hybrid work requiring in-home visits and remote engagement 
• Reliable transportation, valid CA driver’s license, and proof of insurance 
• Knowledge of trauma-informed care principles preferred 
• Certification in case management (CCM) or BSN encouraged  

How to Apply:

Submit your resume and cover letter through our online application portal.  Need an accommodation during the hiring process? Email us at [email protected] – we’re here to help.