Job Summary
The RN Chronic Disease Navigator / Clinical Lead provides advanced nursing support for individuals living with complex chronic conditions including heart failure, COPD, , and multi-morbidity across the City of Kawartha Lakes and Haliburton County.

In addition to direct clinical care, the RN Navigator supports care coordination, pathway implementation, and program development across partner organizations. Working within an interprofessional chronic disease management team, the RN will strengthen collaboration between primary care, hospital services, and community programs to ensure patients receive timely, coordinated, and person-centred care.

This is a mobile, community-based role requiring flexibility to work across partner sites, virtual environments, and home settings.

Responsibilities

Clinical Leadership in Chronic Disease Management
Provide advanced clinical assessment and management support for patients with complex chronic conditions.

Care Navigation and System Integration

Support patient transitions between hospital, primary care, and community services.
Facilitate referrals to appropriate specialty supports and community programs.
Assist patients and caregivers to navigate services across the local health system.

Program Development and Pathway Implementation

Support implementation of Best Care clinical pathways for chronic disease.
Contribute to the development of standardized care processes and referral pathways.
Identify service gaps and opportunities to improve access to chronic disease supports.

Team Collaboration

Participate in interprofessional case conferences and care planning discussions.
Support coordination of services across primary care clinics and community partners.
Contribute to the development of team-based care approaches.

Quality Improvement and Data Use

Participate in quality improvement initiatives aimed at improving chronic disease outcomes.
Support data collection and evaluation related to program utilization, patient outcomes, and service access.
Contribute to continuous improvement of integrated care services.
Support early identification of deterioration and stabilization in community settings.
Collaborate with physicians, nurse practitioners, and specialists to optimize care plans.
Provide consultation to team members regarding best practices in chronic disease management.

Qualifications

Registered Nurse in good standing with the College of Nurses of Ontario
5+ years clinical experience in chronic disease management, community health, primary care, or hospital medicine
Demonstrated experience supporting patients with HF, COPD, or complex multi-morbidity
Experience working in interprofessional teams and collaborative care environments
Strong patient education, coaching, and care coordination skills

Additional Assets

Experience delivering group education or community health programs
Familiarity with digital health platforms or virtual care delivery
Knowledge of local community food programs and social supports
5+ years clinical experience in chronic disease management, community health, primary care, or hospital medicine
Demonstrated experience supporting patients with HF, COPD, or complex multi-morbidity
Experience working in interprofessional teams and collaborative care environments
Strong patient education, coaching, and care coordination skills

Pay: $75,000.00-$95,000.00 per year

Benefits:

Company pension

Work Location: Hybrid remote in Fenelon Falls, ON

Kawartha North Family Health Team jobs

Registered Nurse - Chronic Disease Navigator/Clinical Lead