Home Health Chronic Disease Management Nurse

Company: Ace Home Health Care & Hospice
Location: Mountain View
Posted on: February 13, 2026

Job Description:

Job Description Job Description Are you an experienced home health nurse who loves patient care, but is looking for a slower pace with focus in managing chronic illness? This salaried position would be perfect for you! The ideal candidates will provide high-quality care to patients with chronic conditions, helping them manage their illnesses effectively and improve their overall quality of life. The nurses will be responsible for patient education, coordination of care, and collaborating with the assigned case manager who will monitor patient progress. ACE Home Health Care and Hospice are seeking compassionate and experienced Home Health Chronic Disease Management Nurses to join our healthcare team. Key Responsibilities: Review and update the patients plan of care: Conduct comprehensive review of patient plan of care with chronic conditions (e.g., diabetes, hypertension, COPD, heart disease, etc.) to ensure care plans are personalized and address their specific healthcare needs. Care Coordination: Work closely with physicians, specialists, and other healthcare providers to ensure a coordinated approach to care, including managing referrals, medication reviews, and follow-up appointments. Patient Education and Support: Educate patients and their families on disease management techniques, medication adherence, lifestyle modifications, and self-monitoring practices. Provide emotional and psychological support to patients dealing with chronic illness. Chronic Disease Monitoring: Monitor patient progress through regular check-ins, phone calls, and follow-up visits. Review vital signs, laboratory results, and other indicators to assess the effectiveness of treatment plans. Documentation and Reporting: Maintain accurate, up-to-date patient records, documenting assessments, care plans, interventions, and outcomes in compliance with healthcare regulations and organizational policies. Health Promotion: Advocate for preventive care, promote healthy lifestyle choices, and provide resources for managing chronic conditions outside the clinical setting (e.g., nutrition counseling, exercise programs). Patient Advocacy: Serve as a patient advocate, ensuring they have access to necessary resources and addressing any barriers to care or treatment compliance. Qualifications: Education: Registered Nurse (RN) with an active state license. Bachelor's degree in Nursing (BSN) preferred. Experience: Minimum of 2 years of nursing experience, with at least 1 year in chronic disease management or a related field. Experience working with multidisciplinary team. Skills & Abilities: Strong clinical assessment and critical thinking skills. Ability to communicate effectively with patients, families, and healthcare teams. Knowledge of chronic disease processes, treatment protocols, and healthcare resources. Proficient in electronic health records (EHR) and healthcare software. Ability to work independently and manage a caseload of patients. Location: We have opportunities available in Santa Clara County Salary Range: $120,000-$131,000 per year This position offers a fulfilling opportunity for a skilled nurse to make a meaningful difference in the lives of patients managing chronic diseases. If you are passionate about improving patient outcomes and working in a collaborative environment, we encourage you to apply. Job Type: Full-time Benefits: 401(k) 401(k) matching Dental insurance Employee discount Health insurance Life insurance Paid time off Referral program Vision insurance Work Location: On the road

Keywords: Ace Home Health Care & Hospice, Concord , Home Health Chronic Disease Management Nurse, Healthcare , Mountain View, California