Quality - Registered Nurse Chronic Disease Case Manager

Registered Nurse Chronic Disease Case Manager

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.

• 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 the 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 escalations 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.

• 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

• 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.

• 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…