Clinical Care Coordinator

3 months ago


Hamilton, Canada Ontario Health atHome Full time

**Job Description**:
**Are you a bilingual experienced Registered Nurse 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 Clinical Care Coordinator you will be responsible for providing a “hands-on” and an “in-home” support approach for patients. As an integral part of an interdisciplinary team, the Clinical Care Coordinator will develop care plans to assist patient to live well with their chronic diseases and/or recovery from an acute care admission. Expected outcome is reduced Emergency and hospital admissions and smooth transitions back to the patient’s home. The Clinical Care Coordinator will provide an in-home nursing visit within 72 hours from hospital discharge for identified clientele. The Clinical Care Coordinator conducts a comprehensive nursing assessment, using a patient and family-centered approach and works with the patient and their supports to develop a coordinated service plan in accordance with their goals and assessment.

Additionally, this position is responsible for developing quality, timely and cost effective individual service plans for service provision utilizing a multi-disciplinary approach to achieve optimal health outcomes. The purpose of this position is to provide clinical care as well as care coordination to meet the needs of their identified caseload. The Clinical Care Coordinator facilitates the health care team provide the patient with “wrap around care”.

**What will you do?**
- Engage primary care, providers, and community partners as needed to create a service plan pathway based on patient priorities and goals. The plan can include traditional and cultural activities and is shared with patient/caregivers and partners.
- Acts as a spokesperson as required, within policy and interprets the role of Ontario Health atHome to patients, health care professionals and to the public.
- Develops professional working relationships with team members
- Participates in ongoing clinical education opportunities as arranged or self-directed
- Implements new procedures and controls deemed necessary by management

**What must you have?**
- A Baccalaureate degree from a recognized university in the field of Nursing (and/or a combination of nursing education, training and experience) holding current registration in good standing with the College of Nurses of Ontario.
- Minimum 2-3 years of relevant recent experience as a Registered Nurse working in a clinical setting such as hospital, physician office setting. Sound knowledge of the Ontario health care system and working knowledge of community resources and roles of health care professionals
- Fluent in verbal and written French
- Working knowledge of the nursing process, the consultation process, program planning and crisis management
- Community nursing experience is an asset
- Superior clinical assessment skills
- Solid knowledge of health care related legislation and practices
- Knowledge of direct care/case management models used in community health care organizations to support system navigation and hospital avoidance
- Must have a valid Driver’s License and access to a reliable motor vehicle with appropriate business class liability insurance
- Geriatric experience is an asset

**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 of and adherence to Ontario Health atHome policies, procedures and related practices
- Basic knowledge of and adherence to relevant legislation such as Personal Health Information Protection Act (PHIPA)
- Strong written and verbal communication skills

**Days / Hours of work: Monday to Friday 8:30-4:30**

**French Language Services are required (Bilingual proficiency will be confirmed by a French Language Proficiency Assessment).**

**Projected start date: November 4, 2024 with 7 weeks' mandatory full-time orientation.**

**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

**Who we are?**

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

**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 Commit



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