Registered Nurse Case Manager (Fulltime, ongoing contract)
Share
Job Location:
Monthly Salary:
Posted on:
Vacancies:
Job Summary
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 drivers 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 candidates are invited to submit a cover letter and a detailed resume by December 23 2025 at 4pm. The successful candidate will be required to undergo a criminal background check and medical screening. To be eligible to apply you must have a Social Insurance Number and in some cases a valid work permit. While we thank all applicants only those under consideration will be contacted for an interview.
Thames Valley Family Health Team is an Equal Opportunity employer that is committed to an inclusive safe accessible diverse and respectful environment for all that is free of discrimination and harassment. We encourage and welcome all applicants including but not limited to a broad range of cultural national and ethnic origins racial religious gender identities and expression as well as people of all ages marital/family status and those with disabilities to apply. Please contact if you require assistance with an accommodation.
Required Experience:
Manager
Key Skills
- EMR Systems
- Hospital Experience
- Acute Care
- ICU Experience
- Hospice Care
- Workers' Compensation Law
- Home Care
- Nursing
- Catheterization
- Critical Care Experience
- Medication Administration
- Tube Feeding
About Company
For Patients Find information to help you between visits with our health care team. Read some of our resources before your visit. Program Registration Learn how to manage your health in a virtual setting! Programs include one-time groups and multi-week sessions via Zoom. Patient Surve ... View more
