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
Primary care / Community health / Chronic disease management
Required skills
Holistic health assessment, individualized care planning, goal setting, self-management support, care navigation, referral coordination, follow-up after hospital discharge, clinical documentation, case conferencing, collaboration with GPs and multidisciplinary teams
Preferred skills
Primary or community health experience, understanding of the social model of health, experience with culturally and linguistically diverse communities, digital health systems proficiency
Technologies
Digital health systems, clinical software
Responsibilities
Conduct holistic health assessments and develop individualised care plans; Support goal setting and self‑management, providing health education; Coordinate referrals to multidisciplinary health, social and community services; Provide follow-up after hospital discharge and escalate care where clinical deterioration is identified; Collaborate with GPs and multidisciplinary teams to support integrated, shared-care models; Participate in case conferencing and clinical huddles to strengthen continuity and quality of care
Seniority
Mid-to-Senior level (Minimum 5 years experience)