Quality - Registered Nurse Chronic Disease Case Manager

Unicare Community Health Center•Ontario, CA

3d•Onsite

About The Position

The Registered Nurse Chronic Disease Case Manager provides patient-centered case management and care coordination for individuals 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. The RN collaborates with patients, families, healthcare providers, and interdisciplinary teams to promote chronic disease self-management, continuity of care, preventive health, and timely access to services. The position maintains accurate clinical documentation, follows established care management protocols, works within the scope of licensure, and monitors the work of the care team. The position is primarily office-based within a clinical healthcare environment, with potential travel between clinic sites for patient engagement. The general 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., according to operational needs. Occasional Saturdays may be required.

Requirements

Current, active, and unencumbered California Registered Nurse (RN) license.
Associate degree in Nursing or higher for RN applicants.
Case management experience or equivalent.
Current BLS Certification from the American Heart Association.
Excellent verbal and written communication, organizational, interpersonal, and problem-solving skills.
Knowledge of chronic disease management, care coordination, transitional care, preventive care, and community resources.
Strong clinical judgment, critical thinking, and documentation skills.
Ability to use motivational interviewing, active listening, health coaching, and patient-centered education.
Ability to communicate health information clearly and adapt education to different 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 and collaborate effectively within an interdisciplinary team.
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 role's physical requirements, including prolonged sitting and computer work, frequent fine motor activity, and light to moderate work with lifting or carrying up to 25 pounds.
Ability to travel to other clinic locations as needed.

Nice To Haves

Bachelor of Science in Nursing (BSN).
One to two years of clinical nursing experience, with experience in chronic disease management, ambulatory care, case management, care coordination, population health, managed care, home health, or a related setting strongly preferred.
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 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 the 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.
Maintain patient confidentiality, comply with applicable regulations and organizational policies, and represent the organization professionally.
Participate in performance improvement and continuous quality improvement activities.