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Clinical Care Coordinator – Central Lambton FHT (RN BScN)

Closing Date:
Open until position filled
Job Summary:


JOB TITLE:  Clinical Care Coordinator – Central Lambton FHT (RN BScN)

POSITION:  Full-Time (Monday to Friday 8:30am-4:30pm)

LOCATION:  Erie St. Clair Community Care Access Centre – Sarnia/Lambton site with travel throughout Sarnia/Lambton

SUPERVISOR:  Patient Services Manager

Reporting to the Patient Services Manager, the Clinical Care Coordinator is responsible for providing a "hands-on" and an "in-home" support approach for patients who are described as high user and/or complex by the Central Lambton FHT.  Working as an integral partner with the Primary Care Provider, the Clinical Care Coordinator will provide patients with timely communication, assessment and care coordination and system navigation. The Clinical Care Coordinator supports the patient where they are as needed in various clinical and in home settings – in home, hospital, community, community partner locations.   

The Clinical Care Coordinator will provide in-home comprehensive nursing assessments as required and coordinate interdisciplinary care conferences as needed. 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. 

Nature and Scope:


  • Develop and implement patient and family centered care plans that  support transition from various acute and sub-acute environments to home care site
  • Conducts clinical nursing assessments and provides supplemental information as it relates to services and resources available in the community to assist the patients
  • Develops collaborative working relationships with hospital partners and enhances existing work relationships with a broad range of community agencies, to ensure that caregivers are linked seamlessly to community agencies that can support the patient
  • Collaborates with the care team including primary care and allied health professionals, contracted service providers and community support agencies to develop and delivery care plans that are patient centered to reduce the patient's need to access the emergency room and hospital
  • Designs, in consultation with the patient/caregiver, a coordinated service plan to meet identified needs and goals
  • Based on patients level of need and discharge destination, provides assessment information, advice and recommendations to the receiving agency
  • Authorizes all services, medical supplies and equipment necessary to achieve the established program goal; obtains special authorization as required
  • Ensures the fiscally responsible use of appropriate resources to achieve the desired outcomes by mobilizing and integrating formal and informal patient support networks
  • Collaborates with management team as need to collect data and reports as required 
  • Participate in establishing, maintaining, and monitoring standards for case management. This includes committee work and active participation and contribution to quality and educational initiatives.


  • 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 with a regulated college in Ontario
  • Minimum 3-5 years of relevant recent experience (within the last 3 years) as a Registered Nurse working in the acute care setting
  • Sound knowledge of the Ontario health care system and working knowledge of community resources and roles of health care professionals
  • Canadian Nurses Association (CNA) certification in an area of specialty in  nursing 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
  • Ability to work independently
  • Effective interpersonal and communications skills
  • Must have a valid driver's license and access to a vehicle

Salary is commensurate with qualifications and experience.  Our Clinical Care Coordinators are members of the Ontario Nurses Association. 

Priority consideration will be given to candidates who possess knowledge of Canada's two official languages. 

Qualified individuals are invited to apply in writing by December 12, 2016, quoting posting number ESC 032/16 to:

Human Resources

Erie St. Clair Community Care Access Centre

5415 Tecumseh Road East, 2nd Floor

Windsor ON  N9T 1C5 

FAX:  519 258 7354

We thank all applicants for their interest, but advise that only those selected for an interview will be contacted.

 ESC 032/16                                               Posted: December 2nd, 2016


About the CCAC

Community Care Access Centres (CCACs) connect people across Ontario with quality in‐home and community‐based health care. CCACs provide information, access to qualified care providers and community‐based services to help people come home from hospital or live independently at home.