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Job Summary

The RN-Chronic Disease Case Manager provides patient-centered case management and care coordination for individuals with chronic and complex health conditions. The position 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-Chronic Disease Case Manager works collaboratively 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, and supports quality and patient-centered care within the scope of licensure. The RN-Chronic Disease Case Manager also monitors the work of the care team.

Duties/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, and 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 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 and provide expertise at all care conferences.
- 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.

Non-Essential Functions

- As directed by the Director of Quality Projects and Leadership Development, performs other related and/or necessary tasks to achieve organizational and programmatic goals and objectives.

Professional Requirements

- Adhere to dress code, appearance is neat and clean.
- Maintain patient confidentiality at all times.
- Excellent verbal and written communication skills, including strong organizational and interpersonal skills.
- Report to work on time and as scheduled.
- Maintain regulatory requirements, including all state, federal and local regulations.
- Represent the organization in a positive and professional manner at all times.
- Comply with all organizational policies and standards regarding ethical business practices.
- Communicate the mission, ethics and goals of the organization.
- Participate in performance improvement and continuous quality improvement activities.
- Must have reliable transportation.

Qualifications

- Current, active, and unencumbered California Registered Nurse (RN) license.
- Associate degree in Nursing or higher for RN applicants; BSN preferred.
- Case management experience or equivalent.
- Minimum of 1–2 years of clinical nursing experience preferred, with experience in chronic disease management, ambulatory care, case management, care coordination, population health, managed care, home health, or a related setting strongly preferred.
- Current BLS Certification from the American Heart Association is required.

Knowledge, Skills, and Abilities

- Excellent people skills, with an ability to partner with a dynamic leadership team.
- Knowledge of chronic disease management, care coordination, transitional care, preventive care, and community resources.
- Experience working with patients with chronic or complex medical, behavioral health, or social needs preferred.
- Strong clinical judgment, critical thinking, organization, documentation, and problem-solving skills.
- Excellent communication and interpersonal skills 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 and in a fast-paced environment.
- Proficiency with Electronic Health Records, care management platforms, Microsoft Office, and related technology.
- Bilingual English/Spanish preferred.

Physical Requirements and Environmental Conditions

- Prolonged periods of sitting and working on a computer.
- Pushing and pulling objects up to 25 lbs.
- Frequent wrist, hand, and finger dexterity to perform fine motor function.
- Position requires light to moderate work with 25 lb. maximum weight to lift and carry.
- Full range of body motion requires twisting body, pushing, pulling, reaching, bending, stooping, and handling objects with hands and/or fingers, listening, talking, and/or hearing, and seeing.

Working Conditions

- Primarily office-based within a clinical healthcare environment.
- Frequent interaction with case management team members.
- May require occasional travel between clinic sites.

Work Schedule

- You will generally be scheduled to work each day Monday through Friday, with starting times each day varying between 8:00 a.m. and 9:00 a.m. and ending time between 5:00 p.m. and 6:00 p.m., as required to meet the operational needs of the company. There will be occasional Saturdays.
- You may need to travel to other clinic locations as needed for patient engagement.

Our Mission

The mission of Unicare is to be a community health care organization that treats everyone with dignity, respect and cultural sensitivity to help create an environment in which all can prosper.

Job Details

Pay Type: Hourly

Location: Unicare Community Health Center-Ontario 437, 437 North Euclid Ave, Ontario, California, United States of America