Office Location: Sonoma, CA
Service Area: Sonoma County
Schedule: Part-time, 3 days per week; 8:30 a.m.– 5:00 p.m.
Compensation: $65.00 – $75.00 per hour + additional language differential if bi-lingual in Spanish

Position Summary

As a Home Health Registered Nurse (RN Case Manager), you will provide skilled, compassionate nursing care to patients in their homes — helping them recover, remain independent, and live safely in their chosen environment. You will assess patient needs, develop individualized plans of care, and collaborate closely with physicians, therapists, social workers, and other members of the interdisciplinary team to ensure high-quality outcomes and patient satisfaction. This position offers a meaningful balance of autonomy and teamwork, allowing you to practice the full scope of nursing while being 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 and overseeing all aspects of care.
• 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.

Care Coordination:

• Collaborate with members of the interdisciplinary team — including physical, occupational, and speech therapists, medical social workers, and home health aides — to ensure integrated,
  patient-centered care.
• Communicate effectively with physicians, patients, and families to promote understanding and adherence 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 visit notes.
• 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 care experience 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 and personal 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.

Apply today to join By the Bay Health — where your care makes a difference every day.

This position offers competitive pay, generous benefits and a supportive work environment.

We are seeking a Pediatric Social Worker who will be a member of the interdisciplinary team for providing supportive services to help meet patient/family social, emotional and financial needs related to the impact of a life-limiting illness, loss, and grief.

Schedule:

3 days per week; Monday - Wednesday; 8:30am - 5:00pm

Location:

Sonoma & Napa Counties

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Assess patient/family social and emotional factors to determine ability to cope with terminal illness and death
• Assess family/caregiver capacity to participate in providing care to patient and assist with resources
• Provide individual and family counseling to patient/families in all psychosocial aspects of end-of-life care
• Provide age and developmentally appropriate assessment of and support to siblings as indicated

Education/Experience:

• Master’s degree in social work from a school accredited by the Council on Social Work Education or Masters Degree in mental health discipline
• Minimum one-year’s social work experience in a health care setting
• One year’s social work experience with pediatric patients and families preferred

Certificates, Licenses, Registrations:

• Pediatric ELNEC certification required within the first year

Pay Range:
$46.60 - $58.30 hourly 

We are seeking a Social Worker to become a member of the hospice transdisciplinary team, will be responsible for providing supportive services to help meet patient/family social, emotional, and financial needs related to the impact of a terminal illness, loss, and grief.

Schedule:

Monday - Friday; 8:30am - 5:00pm

Location:

Sonoma County

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Assess patient/family social and emotional factors to determine ability to cope with terminal illness and death
• Assess family/caregiver capacity to participate in providing care to patients and assist with resources
• Provide individual and family counseling to patient/families in all psychosocial aspects of end-of-life care
• Assess environmental resources and obstacles to maintaining safety

Education/Experience:

• Master’s degree in social work from a school accredited by the Council on Social Work Education
• Minimum one-year’s social work experience in acute health care setting
• Hospice or Home Health experience preferred

Certificates, Licenses, Registrations:

• Current California Driver’s License and automobile insurance that meets State of California requirements, if driving a car.

Pay Range:
$44.50 - $52.30 hourly

This position offers competitive pay, generous benefits and a supportive work environment.

We are seeking a Spiritual Support Counselor as a member of the transdisciplinary team and provides spiritual services to patients and their families in agreement with the patient/family's desires and belief system.

Schedule:

Per diem; 2 days a week every week or 6 shifts per month; 8:30am - 5:00pm

Location:

Sonoma County

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Provide spiritual/pastoral services when indicated and appropriate as soon as possible after admission.
• Complete a chaplain’s spiritual assessment for patients requesting spiritual services.
• Provide pastoral/spiritual counseling for patient/family in accordance with patient/family on-going wishes, needs, and applicable traditions including bereavement follow up with family as appropriate.
• Arrange for clergy/spiritual leaders from specific traditions to visit patient/family as needed and appropriate
• Ability to travel between multiple patient sites on a daily basis

Education/Experience:

• Masters degree in Divinity, Theology or related field from an accredited university
• 4 units of Clinical Pastoral Education
• Minimum of one year of experience providing spiritual services, in an acute health care setting, or equivalent experience in a chaplaincy or in pastoral counseling
• Hospice or home health experience preferred

Certificates, Licenses, Registrations:

• Board Certified Chaplain certification preferred

Pay Range:
$35.00 - $43.25 hourly 

This full-time position offers competitive pay, generous benefits and a supportive work environment.

We are seeking a Spiritual Support Counselor as a member of the transdisciplinary team and provides spiritual services to patients and their families in agreement with the patient/family's desires and belief system.

Schedule:

Monday - Friday; 8:30am - 5:00pm

Location:

Sonoma County

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Provide spiritual/pastoral services when indicated and appropriate as soon as possible after admission.
• Complete a chaplain’s spiritual assessment for patients requesting spiritual services.
• Provide pastoral/spiritual counseling for patient/family in accordance with patient/family on-going wishes, needs, and applicable traditions including bereavement follow up with family as appropriate.
• Arrange for clergy/spiritual leaders from specific traditions to visit patient/family as needed and appropriate
• Ability to travel between multiple patient sites on a daily basis

Education/Experience:

• Masters degree in Divinity, Theology or related field from an accredited university
• 4 units of Clinical Pastoral Education
• Minimum of one year of experience providing spiritual services, in an acute health care setting, or equivalent experience in a chaplaincy or in pastoral counseling
• Hospice or home health experience preferred

Certificates, Licenses, Registrations:

• Board Certified Chaplain certification preferred

Pay Range:
$35.00 - $43.25 hourly 

Home Health Physical Therapist (Per Diem – Weekends)

Location: Sonoma & Marin Counties, CA

Schedule: Saturday and Sunday
Pay Range: $69.00 – $76.60 per hour

Making a Difference Every Weekend

By the Bay Health, a nonprofit leader in compassionate care since 1975, is seeking a dedicated Home Health Physical Therapist to join our team on a per diem weekend schedule.

In this role, you’ll help patients regain mobility and independence in the comfort of their homes — working with a supportive interdisciplinary team that values collaboration, flexibility, and clinical excellence.

We take pride in serving our community with compassion and respect, focusing on the physical, emotional, and spiritual well-being of each patient and their family.

What You’ll Do

Patient Evaluation & Care Planning

• Conducts comprehensive initial and ongoing assessments of patient mobility, strength, balance, coordination, pain, and functional status.
• Evaluates home environments for safety and recommends adaptive equipment or modifications as needed.
• Develops and implements individualized Plans of Care (POCs) based on patient needs and physician orders.
• Establishes measurable goals and expected outcomes to restore and/or improve function.

Treatment Implementation

• Provides skilled physical therapy interventions, including but not limited to:
• Gait training and transfer training
• Strengthening and balance exercises
• Range-of-motion and endurance training
• Home exercise program instruction
• Pain management and fall prevention strategies
• Instructs patients, families, and caregivers on safe exercise techniques, use of assistive devices, and energy conservation.
• Modifies treatment as necessary to maximize progress and safety.

Communication & Coordination

• Collaborates with the RN Case Manager, occupational therapy, speech therapy, medical social work, and home health aides.
• Communicates changes in patient condition promptly to the physician and care team.
• Participates in interdisciplinary team meetings and case conferences to review progress and update the care plan.
• Coordinates discharge planning and recommends outpatient or community services when appropriate.

Documentation & Compliance

• Completes all documentation timely and accurately within the EMR system.
• Ensures all visit notes, OASIS data, and progress reports comply with Medicare, CMS, and agency requirements.
• Maintains appropriate visit frequencies per the plan of care and PDGM (Patient-Driven Groupings Model) standards.
• Adheres to agency policies, professional ethics, and confidentiality standards (HIPAA).

Professional Accountability

• Maintains current knowledge of physical therapy techniques, home health regulations, and infection control practices.
• Participates in continuing education, in-service programs, and quality improvement activities.
• Assists in orienting new staff and mentoring colleagues as assigned.

Education & Experience

• Graduate of an accredited Physical Therapy program; Doctor of Physical Therapy (DPT) preferred.
• Minimum of one year of experience in a healthcare setting (home health experience preferred).

 Licenses & Certifications

• Active California Physical Therapy license required
• Current CPR certification

Why Join By the Bay Health

• Competitive per diem pay ($69–$76.50/hour).
• Mileage reimbursement and paid drive time.
• Work/life balance with flexible weekend-only scheduling.
• A supportive, mission-driven environment focused on patient-centered care.
• Opportunities for continued training and professional growth.

About Us

We serve patients and families across Marin, Sonoma, and the greater Bay Area, addressing their practical, emotional, and spiritual needs to maximize quality of life.

We follow all California Department of Public Health (CDPH) vaccine requirements for healthcare personnel.

Ready to Apply?

Bring your skills, compassion, and heart to a team that truly values quality care.
Apply today to join By the Bay Health — where every visit makes a difference.

The Hospice Physician is responsible for overall medical activities of patient care services, related medical administrative components, and medical liaison activities with members of the local medical community.

Hourly rate: $145 - $150 per hour

Hours: 8:30am – 5pm

Location/Position Specific Responsibilities: Sonoma location; In person for IDT meetings 2 times per week.

On-call: Wednesdays from 5pm – 8:30am with an additional $300 per night rate (receiving 2-3 calls)

Supervisory Responsibilities: No direct reports

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Assists in developing the Plan of Care for each patient admitted to the Hospice program and their family, with the coordination of the patient’s attending physician. Maintains liaison with the attending physician and provide consultation with pain and symptom management. The attending physician will be encouraged to provide primary care to his or her home care patient while admitted onto the hospice care program.
• Attends and actively participates in interdisciplinary team meetings in discussion of the care of new and existing hospice patients.
• Reviews on a regular basis, the medical care for each patient currently admitted to the Hospice program. Provides on-going communication with the patient’s attending physician to determine eligibility and statement of prognosis.
• Collaborates with hospice staff to provide effective coordination of services and evaluate delivery of care.
• Consults with team members on an on-call basis for medical issues relating to patient/family Plan of Care.
• Provides 24-hour availability of physician coverage in accordance with agency policy.
• Conforms to all applicable agency policies and procedures and CAHPS regulations. Familiarity with policies related to emergency procedures, communication with Hospice staff, process for grievances, ethical concerns, confidentiality and patient/caregiver rights, safety and infection control.

Education/Experience:

• Licensed physician under the provisions of the California Business and Professions Code
• Board certification from American Board of Hospice & Palliative medicine preferred
• Demonstrated understanding and acceptance of hospice principles of care.

Certificates, Licenses, Registrations:

• Current and active medical physician license in the state of California
• Current DEA license

We are currently seeking a Registered Nurse to serve as a Hospice Nurse Case Manager. This person will be responsible for the provision of skilled nursing assessment, planning and care to maximize the comfort and health of patients and families.

Schedule:

Monday - Friday; 8:30am - 5:00pm

Location: 

Santa Rosa with occasional travel to other areas of Sonoma County

This full-time position offers competitive pay, generous benefits and a supportive work culture including:

• Onboarding that includes didactic training, shadowing across the organization, mentorship by experienced RN
• 3-5 visits per day
• Interdisciplinary teams of 11-15 with a narrow geographical coverage area (multiple teams per county)
• Well-trained and supportive managers with clinical backgrounds
• Supportive and available physicians with hospice & palliative expertise
• Supply ordering to the patient's home
• Organizational support for professional development - education leave and stipend, culture of developing leaders within the organization, clinicians in every level of leadership including CEO
• Support from robust Quality, Education, and Informatics departments

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Provide care in the home and work as a member of the interdisciplinary team comprised of nurses, social workers, chaplains, hospice aides and physicians.
• Coordinate all patient/family services and prioritization of needs, including implementation of the individualized plan of care.

Education/Experience:

• One year experience as a professional nurse in the past three years or Bachelor’s degree in Nursing from an accredited School of Nursing.
• Experience in acute care/ home health and/or hospice setting preferred but not required. 

Certificates, Licenses, Registrations:

• Current license as a registered professional nurse in the State of California.
• Public Health Nursing certification highly desirable.
• HPNA certification preferred.
• Current California Driver’s License and automobile insurance that meets State of California requirements, if driving a car.

Pay Range:
$65.70 - $75.70 hourly

Home Health Physical Therapist 

Location: Sonoma County, CA

Schedule: Part-time; 3 days per week; 8:30am - 5:00pm
Pay Range: $69.00 – $76.60 per hour

What You’ll Do

Patient Evaluation & Care Planning

• Conducts comprehensive initial and ongoing assessments of patient mobility, strength, balance, coordination, pain, and functional status.
• Evaluates home environments for safety and recommends adaptive equipment or modifications as needed.
• Develops and implements individualized Plans of Care (POCs) based on patient needs and physician orders.
• Establishes measurable goals and expected outcomes to restore and/or improve function.

Treatment Implementation

• Provides skilled physical therapy interventions, including but not limited to:
• Gait training and transfer training
• Strengthening and balance exercises
• Range-of-motion and endurance training
• Home exercise program instruction
• Pain management and fall prevention strategies
• Instructs patients, families, and caregivers on safe exercise techniques, use of assistive devices, and energy conservation.
• Modifies treatment as necessary to maximize progress and safety.

Communication & Coordination

• Collaborates with the RN Case Manager, occupational therapy, speech therapy, medical social work, and home health aides.
• Communicates changes in patient condition promptly to the physician and care team.
• Participates in interdisciplinary team meetings and case conferences to review progress and update the care plan.
• Coordinates discharge planning and recommends outpatient or community services when appropriate.

Documentation & Compliance

• Completes all documentation timely and accurately within the EMR system.
• Ensures all visit notes, OASIS data, and progress reports comply with Medicare, CMS, and agency requirements.
• Maintains appropriate visit frequencies per the plan of care and PDGM (Patient-Driven Groupings Model) standards.
• Adheres to agency policies, professional ethics, and confidentiality standards (HIPAA).

Professional Accountability

• Maintains current knowledge of physical therapy techniques, home health regulations, and infection control practices.
• Participates in continuing education, in-service programs, and quality improvement activities.
• Assists in orienting new staff and mentoring colleagues as assigned.

Education & Experience

• Graduate of an accredited Physical Therapy program; Doctor of Physical Therapy (DPT) preferred.
• Minimum of one year of experience in a healthcare setting (home health experience preferred).

 Licenses & Certifications

• Active California Physical Therapy license required
• Current CPR certification

Why Join By the Bay Health

• Competitive per diem pay ($69–$76.50/hour).
• Mileage reimbursement and paid drive time.
• Work/life balance with flexible weekend-only scheduling.
• A supportive, mission-driven environment focused on patient-centered care.
• Opportunities for continued training and professional growth.

About Us

We serve patients and families across Marin, Sonoma, and the greater Bay Area, addressing their practical, emotional, and spiritual needs to maximize quality of life.

We follow all California Department of Public Health (CDPH) vaccine requirements for healthcare personnel.

Ready to Apply?

Bring your skills, compassion, and heart to a team that truly values quality care.
Apply today to join By the Bay Health — where every visit makes a difference.

This full-time position offers competitive pay, generous benefits and a supportive work environment.

The Medical Records Assistant (Patient Care Support Services Assistant) supports Patient Care Support Services Manager by maintaining patient records and provide administrative support in compliance with organization policies and procedures and applicable laws and regulations.

Schedule:

Monday - Friday, 8:30am - 5:00pm; includes weekend and holiday rotations

Location:

On-site; Sonoma with travel to Larkspur office as needed

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel.

Essential Duties & Responsibilities include (but are not limited to):

• Triage all incoming calls from prospective and current patients, caregivers, members of medical community, staff, and public, helping to identify the proper staff member to receive the call in a prompt and courteous manner.
• Daily Audit chart audits by running and reviewing Epic, Excel, PCSS Admit reports for Admission to Discharge patients to ensure accuracy, working with internal departments, individual staff members as well as external medical community and vendors.
• Collects and distributes interoffice mail.
• Facilitates outgoing mail using the USPS mailing system.
• Assist PCSS Manager on special projects as requested

Education/Experience:

• High school diploma or general education degree (GED); or three months related experience and/or training; or equivalent combination of education and experience.
• Minimum of one year’s experience performing clerical/administrative tasks preferably in a health care setting.

Pay Range:
$23.00 - $28.00 hourly