Registered Nurse Case Manager; Fulltime

Registered Nurse Case Manager (Fulltime, ongoing contract)

Thames Valley Family Health Team (TVFHT) is one of the largest and most comprehensive family health teams in Ontario, serving patients across more than 15 sites in four counties. Our mission is to provide collaborative, patient-centered care through an interprofessional team approach that emphasizes innovation, access, equity, and excellence.

The Registered Nurse Case Manager (RNCM) plays a central role in supporting patients with chronic and complex health conditions within a primary care setting. Working to the full scope of nursing practice, the RN is responsible for coordinating, monitoring, and delivering comprehensive, evidence-based care to patients living with chronic health conditions. This role emphasizes care planning, chronic disease self-management support, health promotion, and system navigation.

The RNCM works closely with Primary Care Providers (PCPs), patients, families, and the Interprofessional Healthcare Provider team to optimize care, enhance quality of life, prevent complications, and reduce unnecessary health system use.

Requirements:

• Registered Nurse (RN) in good standing with the College of Nurses of Ontario (CNO).
• Bachelor of Science in Nursing (BScN) preferred
• Minimum 2 years of experience in primary care, community health, or chronic disease management preferred.
• Demonstrated expertise in care coordination, case management, and interprofessional collaboration.
• Strong clinical assessment skills and experience practicing to full scope and implementing medical directives.
• Proficiency with EMRs and virtual care technologies.
• Excellent interpersonal, communication, and documentation skills.
• Knowledge of motivational interviewing, mental health, self-management models, and trauma-informed practices.
• Experience working with vulnerable or marginalized populations is an asset.
• Understanding and sensitivity to diverse cultural, social, and economic backgrounds; commitment to equitable care.
• Valid driver’s license, regular access to a vehicle, and appropriate insurance.
• Ability to work in clinic independently in a team-based, fast-paced environment
• This postion is on site daily.

Responsibilities:

• Conduct comprehensive and routine health assessments, monitoring clinical indicators (e.g., blood pressure, glucose levels, symptoms, lab values) and identifying early signs of deterioration.
• Provide on site clinical support, health coaching, and evidence-based interventions for patients with chronic conditions.
• Perform nursing assessments and authorized controlled acts including medication administration (injections, immunizations), wound care, and other procedures as per CNO standards and medical directives.
• Utilize decision-support tools and evidence-informed protocols to guide care and ensure best practices.
• Lead or co-lead individualized care plans in collaboration with patients, caregivers, PCPs, and other interprofessional team members.
• Track symptoms, monitor progress, and adjust care plans proactively in response to emerging needs.
• Provide proactive outreach and follow-up to ensure continuity, implementation, and evaluation of care plans.
• Support smooth transitions of care between hospital, specialists, home care, and primary care settings.
• Serve as the first point of contact for a designated patient population, ensuring timely response to urgent concerns and coordinating rapid interventions, especially for complex or high-risk patients.
• Educate patients and families on chronic disease management, medications, lifestyle changes, and early warning signs of deterioration.
• Develop and deliver individual or group self-management programs tailored to patient needs.
• Liaise between the clinic, hospitals, specialists, home care, and community agencies to ensure integrated, continuous care.
• Participate in and/or facilitate Coordinated Care Planning (CCP) meetings, aligning with regional care coordination frameworks.
• Maintain ongoing professional development to stay current with best practices in chronic disease management, care coordination, trauma-informed care, and culturally safe care.

Hourly Rate Range: $34.8138 - $42.4559

TO APPLY:

Interested…