Registered NURSE CARE MANAGER

Position Title: Registered Nurse (RN) Care Manager
Hours: Monday to Friday- daytime hours, with one evening shift required per week.

Location: Aurora [with potential to travel to any sites]

Job Type: Permanent Full Time with Healthcare of Ontario Pension Plan (HOOPP)

About Us

Join Southlake Academic Family Health Team (SAFHT) at one of our Interprofessional Primary Care Team (IPCT) expansion sites, delivering comprehensive primary care and enhanced team-based support for patients with complex health needs

Our mission is to address medical and social determinants of health, with a strong emphasis on equitable access for diverse and equity-deserving populations, including vulnerable groups. We deliver care through in-person, virtual, and mobile services.

Our clinic serves as the primary workplace, with occasional travel required within the Northern York Region South Simcoe Ontario Health Team (NYSS-OHT) region and training opportunities at our Southlake Academic Family Health Team (SAFHT) main site.

About the Role

The Registered Nurse Care Manager provides proactive clinical care management for patients with advanced chronic disease, complex health needs, high healthcare utilization and/or palliative care needs. Working in partnership with the patient’s Primary Care Provider (PCP), specialists, hospital teams and community partners, the RN Care Manager maintains a defined caseload of complex patients and provides assessment, individualized care planning, symptom monitoring, education, clinical coordination and transitions-of-care support.

The role focuses on early identification of deterioration,



timely intervention and coordinated care to help patients remain safely in the community and reduce avoidable emergency department visits and hospitalizations.

Key Responsibilities

· Maintain a defined caseload of complex/high-risk patients and complete comprehensive nursing assessments, individualized care plans and ongoing reassessment.

· Support patients with advanced or complex chronic conditions such as CHF, COPD, multimorbidity and other identified priority conditions.

· Monitor symptoms, clinical indicators and changes in health status; identify early deterioration and coordinate timely intervention or escalation.

· Palliative Approach to Care: Identify evolving palliative needs, support symptom monitoring, education and advance care planning within scope, and facilitate connection with specialized palliative services when indicated.

· Collaborate closely with physicians, NPs, Pharmacists, Social Worker Care Managers, RPNs, System Navigators and other team members, ensuring patients receive care from the most appropriate provider.

· Provide education and support to patients and their families, empowering them with the knowledge and tools necessary for effective self-management of their chronic conditions.

· Facilitate and support smooth transitions of care for patients moving between different levels of care,



such as from hospital to home or from primary care to specialist services. Ensure that all aspects of the patient's health and well-being are addressed during these transitions.

· Serve as the first point of contact for the designated patient population, providing rapid access and response to their needs. This includes managing urgent concerns, coordinating timely interventions, and ensuring that patients receive prompt and effective care.

· Maintain accurate and comprehensive documentation in the EMR system.

Qualifications

· Bachelor of Science in Nursing (BScN) from an accredited institution is preferred.

· Active registration and good standing with the College of Nurses of Ontario (CNO); and proof of qualified liability insurance.

· Proficient in using electronic medical records (EMR) systems and other healthcare technology commonly used in Ontario’s primary care settings.

· Strong knowledge of primary care practices, integrated care models, and multidisciplinary team coordination preferred.

· Excellent interpersonal, written and oral communication skills.

· Understanding and sensitivity to the diverse cultural, social, and economic backgrounds of Ontario's patient population, ensuring equitable and accessible care.

· Commitment to ongoing professional development and staying current with best practices in chronic disease management and care coordination.

Expected hours: 37.5 per week

Benefits:

- Company pension
- Dental care
- Disability insurance
- Extended health care
- Life insurance
- Vision care

Application question(s):

- What is your salary expectation

Work Location: In person

📌 Registered Nurse (RN) Care Manager (Aurora)
🏢 Southlake Academic Family Health Team (SAFHT) at one of our Interprofessional Primary Care Team (IPCT)
📍 Aurora