Vancouver Coastal Health

Chronic Disease Care Coordinator (RN)

Job Description

Job Title: Chronic Disease Care Coordinator (RN)
Work Site: Bella Bella Medical Clinic - Bella Bella, BC
Status: Regular Full Time 
Start Date: As soon as possible
Salary: $43.09 - $52.82 per hour


Days off: Saturday, Sunday, and statutory holidays

Reference#: 159255-ndh


Come work as a Chronic Disease Care Coordinator with Vancouver Coastal Health (VCH)! Relocation Assistance and Staff housing may be available.

Vancouver Coastal Health is looking for a Registered Nurse to join the team at the Bella Bella Medical Clinic team as a Chronic Disease Care Coordinator. Apply today to join our team!


As a  Chronic Disease Care Coordinator you will:

  • Support physician practices in office redesign to include comprehensive and coordinated case management skills for Chronic Disease Management (CDM) and prevention using agreed upon best practice quality improvement measures, guidelines and protocols.
  • Collaboratively develop and implement shared care plans that are accessible to other healthcare providers involved in the patient’s care management.
  • Assist individuals to achieve and maintain optimal health through the provision of information/health promotion, disease prevention and treatment services.
  • Within the community multidisciplinary team context, provide continuity of care by assessing patients, liaising with team members, implementing clinical interventions, evaluating patient outcomes, coordinating ongoing care and supporting transition.
  • Act as a clinical resource for the interdisciplinary team by providing information based on specialized theory and practice related to patients with complex heath care needs.
  • Consult, confer, and collaborate with multidisciplinary team members, physicians, educational resources and other health care professions to achieve excellence in patient-centred education and research.



Bella Bella is a beautiful island community off the central coast of British Columbia, 690 km north of Vancouver. It is surrounded by a magical world of channels, inlets and old growth forest. It is home to salmon, orcas, humpbacks, bald eagles and the other denizens of the Pacific Northwest. The climate is mild and the area is a paradise for kayaking, sport fishing, hiking and photography.

The R.W. Large Memorial Hospital in Bella Bella has 7 acute beds, 7 long term care beds and a 4-bed emergency department open 24/7, along with Laboratory and Diagnostic Imaging services. It offers telehealth services as well as speciality clinics. R.W. Large Memorial Hospital also has an Intensive Case Management team for mental health and substance use. There is a medical clinic and a pharmacy located in the hospital. The healthcare team consists of Physicians, RNs, LPNs, PCAs, Laboratory and Radiology Technologists, Combined Lab/X-Ray Technologists, Pharmacist, Pharmacy Assistants, and Support Services Personnel.


R.W. Large Memorial Hospital is located on the traditional territories of the Heiltsuk Nation. It is one of the only provincial hospitals located on a reserve in all of Canada.


For more information, please refer to this link:



Education & Experience

  • Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).

  • Three (3) years’ recent, related nursing experience in chronic disease/complex illness education or chronic disease management and prevention, experience facilitating change, group process and team building, or an equivalent combination of education, training and experience.

  • Valid BC Driver’s License. Local area travel requires the use of a personal vehicle for which mileage will be reimbursed.

Knowledge & Abilities

  • Broad knowledge of nursing science theory, and practice within a client/family centred care model.
  • Comprehensive knowledge of BCCNM standards for nursing practice.
  • Comprehensive knowledge of health care disciplines and their role in chronic disease management and care procedures/processes.
  • Broad knowledge of clinical practice that includes comprehensive and coordinated care for Chronic Disease Management (CDM) and prevention using agreed upon best practice quality improvement measures, guidelines and protocols.
  • Broad knowledge of policies, procedures, and standards of care.
  • Broad knowledge of research methodology and processes, including analytical and evaluation skills.
  • Demonstrated ability in understanding the stages of change/motivational interviewing techniques.
  • Demonstrated ability to function as an effective team member, leader, and facilitator.
  • Demonstrated ability to teach, demonstrate, facilitate and coach.
  • Demonstrated ability to communicate effectively with co-workers, physicians, other health care staff and clients and their families, either one-on-one and in-groups.
  • Demonstrated ability to promote a creative practice change environment.
  • Demonstrated ability to establish workload priorities in collaboration with others.
  • Demonstrated ability to provide effective consultation.
  • Demonstrated ability to work independently and in collaboration with others.
  • Demonstrated ability to deal with and/or guide others in resolution of conflict issues.
  • Demonstrated skill in CPR techniques.
  • Physical ability to perform the duties of the position.
  • Computer literacy with demonstrated wordprocessing, spreadsheet, presentation and database skills

The hours of work including days off and work area may be subject to change consistent with operational requirements and the provision of the Collective Agreement and applicable statutes.

As per the current Public Health Orders (Long Term Care/Seniors Assisted Living Provincial Health Officer Order and the Health Sector Order), as of October 26, 2021, all employees working for Vancouver Coastal Health must be fully vaccinated for COVID-19. Proof of vaccination status will be required.


VCH is a world class innovator in medical care, research and teaching, delivering service to more than one million BC residents. At VCH, we embrace thinking boldly, taking smart risks, and "going first" when we believe it will lead to the best possible outcomes for patients and their families. We invite you to join us in creating healthy lives in healthy communities by showcasing our passion for care, connection to the communities we serve and our culture of teamwork that makes VCH a great place to work.

  • Comprehensive health benefits package, including MSP, extended health and dental and municipal pension plan
  • Grow your career with employer-paid training and leadership development opportunities
  • Wellness supports, including counselling, critical incident and innovative wellness services are available to employees and their immediate families
  • Award-winning recognition programs to honour staff, medical staff and volunteers
  • Access to exclusive discount offers and deals for VCH staff

Diversity, equity, and inclusion are essential to our goals of creating a great place to work and delivering exceptional care. We acknowledge and accommodate unique differences and ensure special measures are in place so that all prospective and current employees are given an opportunity to succeed.

We are committed to building a representative workforce and encourage applications reflecting diversity of sex, sexual orientation, gender identity or expression, racialization or ancestry, disability, political belief, religion, marital or family status, age, and/or status as a First Nation, Metis, Inuit, or Indigenous person.

Vancouver Coastal Health is proud to be recognized as one of Canada's Top 100 Employers in 2022.

Only short-listed applicants will be contacted for this posting.

***Employees of VCH must apply via the Internal Application Process. Refer to the site for How to Apply instructions. Current VCH employees who apply to this posting using this external site will be considered as an external candidate. Seniority will not apply.***

Thank you for your interest in Vancouver Coastal Health.


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