Registered Nurse Care Coordinator – Chronic Disease
Core
Deliver comprehensive chronic disease management, care coordination, and care navigation in community settings to support people with long-term health challenges.
Role type
Registered Nurse Care Coordinator (Chronic Disease)
Builds
Coordinated, person-centred care plans and referrals to multidisciplinary health, social, and community services.
Domain
Healthcare / Chronic Disease Management / Community Health
Deliverable
physical/clinical work
Required skills
Chronic disease management, Holistic health assessment, Care planning, Care coordination, Self-management support, Hospital discharge follow-up, Multidisciplinary collaboration, Clinical documentation
Preferred skills
Primary or community health experience, Social model of health understanding, Work with culturally and linguistically diverse communities, Digital health systems proficiency
Responsibilities
Conduct holistic health assessments and develop individualised care plans, Support goal setting and self‑management, Coordinate referrals to multidisciplinary services, Provide follow-up after hospital discharge, Collaborate with GPs and multidisciplinary teams, Participate in case conferencing and clinical huddles
Seniority
Mid-Senior, hands-on IC