Transitional Care Case Manager

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Job Summary:

Position: Transitional Care Case Manager

Category: Administrative

Employment Type: Employee

Post Date: 10/15/2026

Salary: Negotiable

Close Date: 10/22/2026

Location: CA:ON:Kitchener

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911 Queen's Blvd,Kitchener,ON,N2M 1B2,CA

Transitional Care Case Manager (Job ID: 7129)

Transitional Care Case Manager - Temporary Full Time - until Approximately October 2027.

This is for an existing vacancy.

Location: WRHN

Home to seven regional programs and comprehensive health-care services, Waterloo Regional Health Network (WRHN, pronounced wren) is committed to meeting the current and emerging needs in Waterloo-Wellington and beyond.

WRHN is redefining the health-care experience through collaboration and innovation, addressing barriers to access, advancing care delivery, and setting new standards in compassionate, empowered community-driven health care.

At WRHN, every patient is at the centre of everything we do as we strive to improve lives, inspire healing, and build healthier, stronger communities. By listening to patients and partners, we strive to connect communities to the right care, at the right place, and at the right time.

Please Note: New employees must provide documentation/proof of COVID-19 vaccination status, a 2-step TB test, as well as proof of immunity to measles, mumps, rubella, and varicella (chickenpox) prior to their start date at Waterloo Regional Health Network (WRHN). New Employees will require clearance from Employee Health, Safety and Wellness before they are able to begin any position within WRHN.

Position Summary

The Transitional Care Case Manager is a regulated healthcare professional who plays a central role in coordinating safe, timely, and effective discharge planning and care transitions. Operating within an interdisciplinary team, the Transitional Care Case Manager enhances patient outcomes, ensures continuity of care, and supports optimal utilization of health resources through active collaboration with patients, families, hospital teams, and community partners.

This role is aligned with Ontario Health’s Home First philosophy and best practices in Alternate Level of Care (ALC) management. The Transitional Care Case Manager acts as a clinical leader in discharge planning, proactively identifying patient needs and barriers early in the care journey.

Responsibilities

Discharge Planning and Coordination

• Initiates discharge planning at admission, including completing a comprehensive interprofessional assessment within 48 hours with patients identifies as high risk as being designated ALC.
• Establishes and communicates an Estimated Date of Discharge (EDD) in collaboration with the Most Responsible Physician.
• Develops individualized discharge plans, shared with patients and families at least 48 hours prior to discharge.
• Ensures appropriate referrals to community partners, including but not limited to Ontario Health at Home (OHaH), Community Support Services, Hospital-to-Home (H2H) program, Paramedicine team etc.

Risk Identification and Assessment

• Screens all admissions within 24 hours to identify high-risk discharges using standardized assessment tools.
• Gathers and documents pre-admission functional status, demographic data, caregiver supports, and barriers to discharge.

Interdisciplinary Collaboration

• Collaborate daily with the interprofessional team, including the Most Responsible Physician (MRP), Occupational and Physiotherapist, Resource Person and Social Worker to maintain and revise discharge plans.
• Participates in interprofessional discharge rounds and case conferences to address care needs, services coordination, and planning.

Communication and Documentation

• Clearly communicates discharge plans to patients, families, and the care team.
• Maintains accurate documentation in Cerner and other relevant systems.
• Attends and contributes to bullet rounds, tracking and addressing MSRD and ALC and length of stay metrics.
• Ensures follow-up appointments with Primary Care Physician are scheduled within 1–7 days.

System Navigation and Advocacy

• Coordinates with Ontari