Complex Care Coordinator

This is a Temporary Full-time position up to approximately twelve (12) months.

Sinai Health is seeking a Complex Care Coordinator / Social Worker to support the Mount Sinai Academic Family Health Team (MSAFHT) at the Mount Sinai Hospital campus. This role supports patients with complex needs who require assistance navigating health and community care systems to achieve coordinated, integrated, and patient-centered care. The Complex Care Coordinator / Social Worker delivers comprehensive social work services, including assessment, care coordination, counseling, and community referral. Working as part of an interprofessional primary care team, the role addresses psychosocial concerns, social determinants of health, and system navigation, while supporting continuity of care and appropriate follow-up in the community. Reporting to the Director of the MSAFHT, the Complex Care Coordinator / Social Worker supports a diverse, urban patient population with complex social and health-related needs. The role contributes to equitable care through advocacy, coordination, and strong partnerships with community-based services.

About The Mount Sinai Academic Family Health Team

The Mount Sinai Academic Family Health Team delivers comprehensive, patient-centered primary care across the lifespan. Our goal is to support patients in managing their health and improving overall quality of life through integrated primary care and specialized programs.

The Family Health Team operates at two locations, the Granovsky Gluskin Family Medicine Centre in Toronto and the Sherman Health and Wellness Centre in Vaughan.

Family Health Teams bring together multiple primary care providers to function as a coordinated care team. This model allows patients to access a broad range of services in one setting. The interprofessional team includes physicians, nurses, social workers, pharmacists, and other specialized health care providers. As a teaching clinic, the MSAFHT works closely with the University of Toronto Department of Family and Community Medicine, supporting medical students and residents. The team values education, research, quality improvement, and collaborative patient care.

In this role you will:

• Work collaboratively with the interprofessional Family Health Team to support patients with complex health and social needs
• Identify and provide resources to support patients and families in making informed health decisions
• Assist patients in exploring options and developing action plans while providing guidance and support
• Provide referrals to social, personal, and community services, including legal, medical, financial, housing, employment, transportation, and childcare resources
• Liaise and collaborate with community agencies, care coordinators, social workers, and other service providers to identify and coordinate appropriate supports
• Participate in the selection and admission of patients to appropriate programs in partnership with community agencies
• Assess and determine eligibility for social benefits and income support programs
• Manage funds or resources dedicated to supporting patients in need, ensuring equitable allocation and accountability
• Monitor patient progress, provide support, and address emerging challenges
• Advise and support recipients of social assistance, pensions, and related benefits
• Implement and coordinate delivery of services within the community in collaboration with external providers
• Maintain ongoing communication with social service agencies and health care providers to ensure coordinated care and continuity of services
• Run regular complex care rounds to review patient cases as a team, identify gaps, and plan integrated interventions
• Contribute to the development of coordinated care plans as needed to support integrated, patient-centered care
• Support seamless transitions from acute or tertiary care to primary and community care, including booking follow-up appointments and linking patients to home and community supports
• Attend relevant team meetings, case conferences, and community planning sessions to support integrated care
• Perform other duties consistent with the job classification as required

Job Requirements

Job Requirements

Mandatory

• Successful completion of a Masters of Social Work from an accredited educational institution
• Currently registered and in good standing with the Ontario College of Social Workers and Social Service Workers
• 3 years of experience in primary care, community-based care, or a similar interdisciplinary setting

Preferred

• Experience supporting individuals coping with grief, trauma, and/or abuse
• Experience working with populations experiencing social complexity, including poverty, housing instability, and systemic barriers
• Experience contributing to interprofessional team planning or case conferencing

Skills and Knowledge

• Knowledge of contemporary social work theories, frameworks, and standards of practice
• Understanding of care coordination principles and best practices within primary care settings
• Knowledge of chronic disease management, mental health, and social determinants of health
• Strong understanding of community services, social support systems, and health care delivery models, including referral pathways
• Demonstrated experience working with complex, high needs, or medically fragile patients, including care coordination and patient advocacy
• Ability to conduct comprehensive psychosocial assessments, develop coordinated care plans, and monitor and adjust plans as needed
• Knowledge of privacy legislation and confidentiality requirements, including PHIPA, with sound judgement in professional practice
• Proficiency in electronic medical records and clinical documentation standards
• Excellent communication, interpersonal, and organizational skills, with the ability to manage competing priorities and high volume caseloads
• Strong problem solving and critical thinking skills related to complex case management
• Ability to work both independently and collaboratively within an interprofessional team
• Cultural competence and ability to work effectively with diverse patient populations
• Commitment to equity, patient centered care, and improved health outcomes
• Demonstrated reliability, including satisfactory attendance and work performance

If this sounds like you and you feel ready to advance your social work career within family health, apply now and let us know why you would be a great addition to our team.