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Full-Time Clinical Care Coordinator - eRehab (RN/BScN)

Closing Date:
Open until position filled
Job Summary:

​Posting ESC 029/16

JOB TITLE:  Clinical Care Coordinator - eRehab (RN/BScN)

POSITION:   Full-Time

LOCATION:   Erie St. Clair Community Care Access Centre – WINDSOR SITE with travel throughout Windsor – Essex

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 being discharged from acute care and require in home therapy. The Clinical Care Coordinator will provide patients with timely communication and linkage to community rehabilitation therapy based on the evidence informed practice for specific disease management.  The mild and moderate stroke patient will be the initial patient population and may include others in the future. 

As an integral part of an interdisciplinary team, the Clinical Care Coordinator will develop coordinated care plans to assist patients as they recover from their acute illness. Expected outcome is reduced acute care length of stay, emergency and hospital admissions and timely rehabilitation. The Clinical Care Coordinator will provide in-home nursing visits as required and coordinate the first interdisciplinary team visit within 24 hours from hospital discharge. The Clinical Care Coordinator will conduct a comprehensive nursing assessment, using a patient centered focus and will work with the patient and their supports to develop a coordinated service plan.  

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 as well as care coordination to meet the needs of complex patients as identified by the Health Links community partners. 

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, 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 2 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
  • Experience working with stroke patients required
  • Emergency/critical care and community nursing experience is an asset
  • Canadian Nurses Association (CNA) certification in an area of specialty: Certificate in Geriatric Nursing (GNC), Neuroscience or Rehabilitation nursing 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 9th 2016, quoting posting number ESC 029/16 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.

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.