Reporting to the Manager, Care Management & System Navigation, the Care Management Leader:

• Practices in accordance with BCCNM standards and code of ethics.
• Follows a client and family-centered care model aligned with PHC's vision and values.
• Coordinates and collaborates with the acute interprofessional team from admission to discharge.
• Conducts comprehensive nursing assessments and directs the interprofessional team on care and interventions.
• Secures funding and approvals for necessary services.
• Develops and implements policies, procedures, and standards for effective care management and discharge planning.
• Participates in committees, task groups, continuing education, and corporate initiatives.
• Uses data to focus efforts, measure progress, and ensure patient-focused, high-quality, efficient, and effective care.

Education 

• Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM). 
• Three (3) years recent, related experience including (1) year of experience in community care and discharge planning or an equivalent combination of education, training and experience.

Skills and Abilities

• Comprehensive knowledge of Nursing theory and practice within a patient/family centred model of care.
• Comprehensive knowledge of the BCCNM standards for nursing practice.
• Broad knowledge of evidence based nursing practice related to various patient population groups and demonstrated ability to apply knowledge to a case management process.
• Broad knowledge of pathophysiology and pharmacology, and demonstrated ability to apply knowledge to safely-plan discharge.
• Broad knowledge of biological and pathophysiological indicators related to severity of illness to apply medical appropriateness criteria to resource utilization and transition/discharge planning.
• Broad knowledge of the illness or disease process and potential long-term complications.
• Broad knowledge of other health care disciplines and their role in patient care.
• Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment.
• Broad knowledge of external agencies and community resources.
• Demonstrated ability to engage in comprehensive assessment, observation and monitoring of patients.
• Demonstrated ability to plan, organize, and prioritize work.
• Demonstrated ability to analyze situations, problem solve, deal with conflict, and negotiate resolutions in a timely manner.
• Demonstrated ability to provide leadership, work direction and consultation.
• Demonstrated ability to work independently and as a member of an interprofessional team.
• Demonstrated ability to develop and maintain collaborative working relationships and communicate (orally and in writing) effectively with clients and their families, coworkers, physicians, other health care staff, and staff of external agencies.
• Demonstrated computer skills including the ability to effectively use computerized client care information system.
• Physical ability to carry out the duties of the position.
  
  

• State-of-the-art facilities:  The new St. Paul’s Hospital and health campus will be the most innovative approach to the delivery of integrated care in B.C. and Canada, designed to appropriately address the future health needs of patients, families and our communities. From hospital care to primary and community health solutions, the new St. Paul’s Hospital and health campus will continue to lead innovations in care, research, and teaching. The new St. Paul’s Hospital is expected to open in 2027.
• A competitive salary: $49.20-$63.47 CAD / hr
• Inclusive culture: We respect the diversity, dignity and interdependence of all persons. We value the cultural richness that our diverse workforce brings to the care of our equally diverse population of patients and residents.

Your Day to Day:

Care Coordination and Discharge Planning

• Leads care coordination and discharge planning by collaborating with the interprofessional team.
• Develops medical and functional goals, assigns tasks, and ensures timely discharge.

Patient Flow and Resource Management

• Facilitates patient flow by identifying those needing specialized attention or alternate care levels.
• Acts as a resource for referrals related to diagnoses and post-discharge care.

Patient Monitoring and Care Plan Adjustment

• Observes and evaluates patient progress, symptoms, and behavioral changes.
• Revises care plans with the team to ensure high-quality, patient-focused care.

Policy Development and Implementation

• Develops and recommends policies and procedures for care management and discharge planning.
• Promotes best practices by identifying and revising policies and procedures.

Interprofessional Collaboration

• Consults with physicians, case managers, and the interprofessional team to resolve patient care issues.
• Leads multidisciplinary team conferences and develops partnerships with other facilities.

Patient Advocacy and Education

• Acts as a patient advocate, protecting rights to autonomy, respect, privacy, dignity, and information.
• Provides support and information to families, physicians, and other professionals about disease management and resources.

Training and Professional Development

• Participates in the orientation of new team members by providing training and mentorship.
• Maintains and updates clinical knowledge and develops a professional development plan.

We acknowledge that Providence Health Care & the new St. Paul’s Hospital site is located on the traditional, ancestral, and unceded territory of the Coast Salish Peoples, including the territories of the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), and Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) Nations.