Clinical Care Coordinator

4 weeks ago


Toronto, Ontario, Canada North York General Hospital Full time

Job Summary

North York General Hospital (NYGH) is seeking a skilled Clinical Care Coordinator to join our team. As a key member of our Transitional Care Program, you will play a vital role in providing clinical support, patient and family education, and comprehensive care facilitation for NYG@home and the NYCARES integrated care initiative.

Key Responsibilities

  • Onboard eligible patients and caregivers, providing education and engagement
  • Support patient navigation through care pathways, assessments, planning, implementation, evaluation, and documentation
  • Coordinate with hospital and community staff to facilitate discharge planning meetings and follow up with primary care providers, hospital physicians, and specialists as needed
  • Ensure timely patient access to appointments, tests, and follow-up care
  • Use clinical expertise to direct or modify care pathways to meet patient needs
  • Facilitate advance care planning with the most appropriate provider
  • Lead and facilitate inter-professional patient care rounds and case conferences as needed
  • Be the primary contact for patients, families, and care providers in the hospital and community
  • Enable the flow of information in adherence with privacy legislation
  • Facilitate seamless transitions across the care continuum
  • Contribute to the hospital's and Ontario Health Team's mission, vision, values, and strategic direction

Requirements

  • Regulated healthcare professional required
  • Current registration, in good standing with the applicable college required
  • Minimum three years' community care experience
  • Demonstrated expertise in the management and care coordination for seniors, patients with complex care needs, chronic diseases, mental health, and addictions, and/or palliative care
  • Experience providing patient education
  • Strong commitment to Patient and Family Centered Care
  • Expert clinical skills in the assessment, planning, implementing, evaluating, and documenting of the delivery and coordination of care for patients and their families living with chronic disease and/or elderly patients with medical needs
  • Strong leadership, critical thinking, decision making, problem recognition, and solving skills
  • Solid understanding of community services and supports
  • Current experience working collaboratively with and leading a multi-disciplinary team
  • Excellent communication and interpersonal skills
  • Experience in evaluation and quality improvement
  • Experience with project implementation and evaluation preferred
  • Experience working with seniors in a clinical or community setting preferred
  • Bilingualism in French/English an asset


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