Nurse Case Manager

Canadian Mental Health Association Toronto Branch • Toronto, ON

11d • Onsite

About The Position

The Nurse Case Manager – Primary Care delivers comprehensive, person‑centred primary health care within an integrated primary care and mental health setting. The role focuses on addressing complex, multi‑faceted health needs, including chronic disease, preventive care, mental health and substance use concerns, and the impacts of social inequities on health and access to care. As part of an interprofessional team, the Nurse Case Manager provides and coordinates primary care services, supporting physical health, early intervention, disease prevention, and ongoing management of complex and chronic conditions. The role emphasizes continuity of care, care coordination, health system navigation, and reducing barriers related to the social determinants of health to improve access and outcomes. Practice is grounded in primary health care principles, including recovery-oriented practice, harm reduction, and culturally responsive care for diverse populations.

Requirements

• Degree in nursing and Registration with Ontario College of Nurses
• Minimum 2+ years of nursing experience, preferably in primary care, community health, or ambulatory settings
• Experience conducting intake assessments, health histories, triage, and ongoing care
• Strong background in chronic disease management, health promotion, and preventive care
• Demonstrated ability to work independently and collaboratively within interprofessional teams
• Experience providing consultative and educational support to healthcare and community partners
• Clinical knowledge of physical and mental health conditions in primary care or community settings
• Ability to conduct holistic assessments and use screening tools to inform care planning
• Knowledge of physical and psychotropic medications, including monitoring and adherence support
• Skilled in recovery‑oriented, trauma‑informed, and client‑centred practice
• Strong collaboration and referral‑coordination skills within interprofessional and community systems

Nice To Haves

• Certification in primary care training is an asset
• Personal experience with mental health challenges, whether firsthand or through a loved one, is considered an asset

Responsibilities

• Conduct holistic health assessments addressing physical, mental health, and psychosocial needs
• Provide nursing interventions including health education, chronic disease management, medication support, and treatment monitoring
• Support clients with co‑occurring mental health, substance use, and physical health conditions
• Monitor changes in client health status and collaborate with Nurse Practitioners and the care team to adjust care plans
• Coordinate care across primary care, mental health, hospitals, and community services
• Develop and monitor individualized care plans in collaboration with clients and the interprofessional team
• Facilitate referrals and link clients to housing, income supports, social services, and specialized care
• Advocate to reduce barriers and support continuity of care
• Collaborate with physicians, nurse practitioners, social workers, case managers, peer workers, and other team members
• Participate in case conferences, care planning, program development, and quality improvement activities
• Build therapeutic, trauma‑informed, recovery‑oriented relationships
• Support client self‑management, goal‑setting, and informed decision‑making using harm reduction and culturally safe approaches
• Maintain accurate, timely clinical documentation in accordance with policies and legislative requirements
• Contribute to program outcomes tracking, evaluation, and continuity of care
• Assess and respond to changes in clinical status, including crisis intervention and appropriate referrals

Benefits

• Health Care of Ontario Pension Plan (HOOPP), a predictable, secure monthly income upon retirement
• Comprehensive Group Health Insurance – Health, Dental, Vision, Paramedicals
• Short-term and Long-term Disability programs and life insurance to protect your income upon illness or injury
• Work-life balance and flexibility
• Annual Professional Development Funding for career learning and advancement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level