Chronic Disease Manager

4 weeks ago

Surrey, British Columbia, Canada Fraser Health Full time
Job Summary

We are seeking a highly skilled and compassionate Community Health Nurse to join our team at Fraser Health. As a key member of our interprofessional team, you will work closely with clients, families, and healthcare providers to provide high-quality care and support.

Key Responsibilities
  • Conduct comprehensive assessments and develop individualized care plans to meet the unique needs of clients with complex chronic conditions.
  • Provide direct client care, including health counseling, education, and self-management support, to promote optimal health outcomes.
  • Collaborate with healthcare providers, community resources, and family members to coordinate care and services, ensuring a seamless transition across the healthcare continuum.
  • Develop and implement care plans that address the physical, emotional, and social needs of clients, with a focus on promoting independence and dignity.
  • Communicate effectively with clients, families, and healthcare providers to ensure that care plans are aligned with client goals and preferences.
  • Participate in quality improvement initiatives and contribute to the development of policies and procedures that promote best practices in community health nursing.
Requirements
  • Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
  • One year recent related clinical experience assessing and treating complex geriatric and/or adult patients with chronic health conditions in an acute or community/outpatient care setting.
  • Valid BC Driver's license and access to a personal vehicle for business-related purposes.
Preferred Qualifications
  • Demonstrated knowledge, skills, and competence in gerontology and adults living with complex frailty and chronic illnesses.
  • Ability to communicate effectively, both verbally and in writing, with clients, families, and healthcare providers.
  • Ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively and make informed decisions.

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