Quality - Registered Nurse Chronic Disease Case Manager

Unicare Community Health Center Inc, Recruiter•Ontario, CA

4d•Onsite

About The Position

The RN–Chronic Disease Case Manager provides patient-centered case management and care coordination for people with chronic and complex health conditions. The role engages patients, identifies care needs and barriers, coordinates services across providers and community resources, and supports individualized care plans to improve health outcomes and quality of life. Working collaboratively with patients, families, healthcare providers, and interdisciplinary teams, the position promotes chronic disease self-management, continuity of care, preventive health, and timely access to services. The RN maintains accurate clinical documentation, follows established care management protocols, and supports quality, patient-centered care within the scope of licensure. The role also monitors the work of the care team. The position is primarily office-based within a clinical healthcare environment and may involve occasional travel between clinic locations. The usual schedule is Monday through Friday, with start times between 8:00 a.m. and 9:00 a.m. and end times between 5:00 p.m. and 6:00 p.m., as operational needs require. Occasional Saturdays may be required.

Requirements

Current, active, and unencumbered California Registered Nurse (RN) license.
Associate degree in Nursing or higher.
Case management experience or equivalent.
Current BLS Certification from the American Heart Association is required.
Excellent verbal and written communication skills, including strong organizational and interpersonal skills.
Knowledge of chronic disease management, care coordination, transitional care, preventive care, and community resources.
Strong clinical judgment, critical thinking, organization, documentation, and problem-solving skills.
Ability to communicate effectively with patients, families, providers, and interdisciplinary teams.
Ability to use motivational interviewing, active listening, health coaching, and patient-centered education.
Ability to communicate health information clearly and adapt education to varying levels of health literacy.
Ability to recognize changes in patient condition and appropriately escalate concerns within scope of practice.
Ability to manage an assigned patient panel and prioritize needs based on risk, acuity, and care goals.
Ability to work independently while collaborating effectively within an interdisciplinary team.
Commitment to patient-centered care, health equity, cultural humility, quality improvement, and professional development.
Ability to maintain confidentiality and comply with HIPAA, organizational policies, and applicable regulations.
Ability to work effectively with diverse patient populations in a fast-paced environment.
Proficiency with Electronic Health Records, care management platforms, Microsoft Office, and related technology.
Reliable transportation.
Ability to meet the stated physical requirements, including prolonged sitting and computer work, frequent fine-motor activity, and lifting or carrying up to 25 pounds.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Minimum of 1–2 years of clinical nursing experience, preferred, particularly in chronic disease management, ambulatory care, case management, care coordination, population health, managed care, home health, or a related setting.
Experience working with patients with chronic or complex medical, behavioral health, or social needs.
Bilingual English/Spanish.

Responsibilities

Manage an assigned panel of patients with chronic and complex health conditions.
Conduct patient outreach, clinical assessments, follow-up, and ongoing care coordination within scope of practice.
Develop, implement, and update individualized care plans based on patient needs and established clinical protocols.
Advocate for patients and help address barriers related to access, health literacy, transportation, housing, food insecurity, and other social needs.
Coordinate care with primary care providers, specialists, behavioral health providers, pharmacies, community health workers, and care coordination specialists.
Support patients in managing chronic conditions, medications, symptoms, and recommended treatment plans.
Provide clear, disease-specific education to promote patient understanding and self-management.
Use motivational interviewing, active listening, and health coaching to strengthen patient engagement.
Identify clinical, behavioral, social, and environmental barriers that may affect patient outcomes.
Direct and oversee implementation of care coordinators and community health workers to connect patients with appropriate healthcare, behavioral health, and community-based resources.
Facilitate transitions of care following hospitalizations, emergency department visits, skilled nursing stays, and other changes in care.
Monitor patient progress and care-plan goals, identifying gaps or changes that require intervention.
Attend care conferences and provide expertise.
Communicate relevant patient updates and care needs to providers and interdisciplinary team members.
Recognize changes in patient condition and escalate concerns according to established protocols and scope of practice.
Maintain timely, accurate, and complete documentation in the Electronic Health Record and other required systems.
Participate in case conferences, interdisciplinary meetings, quality improvement initiatives, and utilization review activities as assigned.
Identify opportunities to improve outcomes, close care gaps, and reduce avoidable emergency department visits and hospitalizations.
Maintain current knowledge of chronic disease management, care coordination practices, community resources, and applicable organizational and regulatory requirements.
Participate in group patient visits focused on lifestyle change.
Perform other related or necessary tasks, as directed by the Director of Quality Projects and Leadership Development, to achieve organizational and programmatic goals and objectives.
Adhere to the dress code and maintain a neat, clean appearance.
Maintain patient confidentiality and comply with HIPAA, organizational policies, and applicable regulatory requirements.
Report to work on time and as scheduled.
Represent the organization positively and professionally, comply with ethical business practices, and communicate its mission, ethics, and goals.
Participate in performance improvement and continuous quality improvement activities.
Maintain reliable transportation and travel to other clinic locations as needed for patient engagement.