RN Chronic Disease Care Navigator

Unicare Community Health Center Inc, Recruiter; Ontario (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Unicare Community Health Center Inc, Recruiter is seeking a Registered Nurse – Chronic Disease Case Manager to provide patient-centered care coordination for individuals with chronic conditions. You will engage patients, assess needs, develop individualized care plans, and collaborate with a wide care team to improve outcomes.

You will monitor care delivery, support transitions, and advocate for access to services and social resources while maintaining HIPAA-compliant documentation within our

Qualifications

• RN license and active California registration required.
• Minimum 1–2 years of clinical nursing with chronic disease or ambulatory care experience preferred.
• Experience with chronic disease management and care coordination strongly preferred.

Responsibilities

• Manage an assigned panel of patients with chronic and complex health conditions.
• Conduct patient outreach, assessments, and ongoing care coordination within scope of practice.
• Develop and update individualized care plans per clinical protocols.
• Advocate for patients to address barriers to access, housing, transportation, and social needs.
• Coordinate care with primary care providers, specialists, behavioral health, pharmacies, and community health workers.
• Support patients in managing conditions, medications, symptoms, and treatment plans.
• Provide disease-specific education to promote self-management.
• Utilize motivational interviewing and health coaching to enhance engagement.
• Identify barriers affecting outcomes and escalate as needed.
• Direct care coordinators and community health workers to appropriate resources.
• Facilitate transitions of care after hospitalizations or ED visits.
• Monitor progress and update care plans to close gaps in care.

Skills

Case management

Motivational interviewing

Health coaching

Communication

HIPAA compliance

Bilingual English/Spanish

Documentation

Interdisciplinary teamwork

Patient-centered care

Care coordination

Education

Associate degree in Nursing

BSN preferred

California RN license

Current BLS Certification

Job description

Unicare Community Health Center Inc, Recruiter is seeking a Registered Nurse – Chronic Disease Case Manager to provide patient-centered care coordination for individuals with chronic conditions. You will engage patients, assess needs, develop individualized care plans, and collaborate with a wide care team to improve outcomes.

You will monitor care delivery, support transitions, and advocate for access to services and social resources while maintaining HIPAA-compliant documentation within our