Job Description

CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker (MSW), dietitian, or speech language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

As a Care Coordinator, you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health care practitioners.

Whether you work in our office, in the community, or a health care facility – you will play a lead role in providing connected, accessible, patient-centred care – and be supported by our collaborative team that includes over 9,000 regulated health care and other professionals.

As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work-life balance.

What will you do?

Under the general direction of the Manager, Patient Services and in accordance with the Ontario Health atHome Champlain standards, legislation, policies and guidelines, the Care Coordinator is responsible for client assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all client service programs (home care and placement), including the provision of community resource information and referral.

As a member of the Community Float Team, the Care Coordinator will work collaboratively with patients, families, caregivers, and hospital partners to develop a care plan to support a safe transfer from hospital to home for both complex and non-complex patients. Care Coordinators must prioritize work based on the ever changing needs of patients and hospital environment while meeting the Ontario Health atHome Champlain Guidelines of Care. The Care Coordinator will participate in various meetings to support care planning and communication with partners within the circle of care, including family meetings, care conferences, bullet rounds, and joint discharge rounds.

Primary Responsibilities:

• Identification and Engagement – Assesses referred clients for admission and establishes a helping relationship with eligible clients and their families while honoring the client’s values and preferences
• Assessment – Performs multi-dimensional assessment and identifies the need for crisis intervention and/or prevention strategies
• Goal Setting and Service Planning – Establishes a care and service plan balancing client’s needs, choices and available resources. Develops a care plan in collaboration with the client, other health care professionals, care providers or family, stating priorities, services authorized, mutual goals and anticipated duration of service
• Accessing Resources and Linking – Collaborates and partners with the networks of service providers.
• Service Implementation – Initiates and authorizes the implementation of the care plan
• Accountability, Monitoring and Reassessment – Reviews and maintains care plan in compliance to quality standards, outcome measures, quality indicators
• Discharge Planning – Conducts discharges from service process and/or redirects clients and families to alternative resources

Team/Department: Community Float

Hours of work: 8:30am-4:30pm – Monday to Friday

Length of Temporary Assignment: November 20, 2026

FTE: 1.0

Starting Salary: $44.480/hr to $47.517/hr

Affiliation: OPSEU

Reporting to: Manager, Patient Services

Office Location: Labelle

What must you have?

• Registered Nurse (BScN or diploma) and registered with the College of Nurses of Ontario; or
• Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
• Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
• Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers; or
• Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario; or
• Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
• All of the above require at least 2 years related professional experience
• Fluency in English and French is required
• We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

Knowledge:

• Knowledge of health care delivery system and community resources within the Champlain region
• Medical conditions and cognitive/psychiatric disorders
• Client centered, multi-disciplinary team approach to client care
• Proficient in the use of computerized processes including the use of mobile (laptop) technology

Skills and Abilities:

• Demonstrates effective time management and organizational skills
• Effective decision-making and problem-solving in crisis situations
• Ability to negotiate and implement an effective goal-oriented, client-centered care plan
• Team player with ability to accept and adapt to change
• Ability to maintain a positive attitude in stressful situations
• Ability to organize daily workload in the presence of frequent interruptions
• Vulnerable Sector Check completed within the last six months

Hours of Work

Monday to Friday – 8:30am to 4:30pm (35hrs/week)

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer: ​

• Attractive comprehensive compensation packages and benefits​
• Valuable development opportunities​
• Membership in a world class defined benefit pension plan
• Salary: $44.480/hr to $47.517/hr​

Who are we?

We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred care.

Why join us?

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Ontario Health atHome is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.

This job posting is for an existing vacancy.