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South East

Care Coordinator

Closing Date:
Open until position filled
Job Summary:

Care Coordinators are responsible for patient assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all patient service programs (in-home and placement), including the provision of community resource information and referral.  Care Coordinators are health system navigators who link patients with the right information and resources to help them achieve their short and long-term health care goals.



  • Assesses referred patients for eligibility of services utilizing established criteria;
  • Assists in identifying complex patients within the CCAC in accordance with the Health Link definition of complex
  • Assists ineligible patients to access information/services appropriate to their needs and provides information on community resources and assistance to access the same where required;
  • Acts as primary contact for patients, communicating with patients, caregivers, contracted service providers, primary care and Health Link partners regarding service plans;
  • Collaborates with the patient, caregiver and/or family, and appropriate members of the patient's health team related to  service plan development , priority determination, authorization of services, development of mutual goals, and anticipated duration of service(s) outlined;
  • Provides Care Coordination for identified Health Link patients and coordinates the primary Care Coordinator assignment with applicable Health Link partner
  • Coordinates the delivery of quality, cost effective, equitable and timely services;
  • Collaborates with service providers and other system partners;
  • Fosters overall integration with primary care to develop strong working relationships centered on integrated patient care
  • Maintains patient records which support ongoing assessment and monitoring, and meets the relevant discipline and standards, and documents both written and electronically, in accordance with the College and other standards to support the team;
  • Effectively communicates with all appropriate members of the patient's healthcare team via established communication channels including case conferences and home visits to optimize care planning and appropriate services;
  • In collaboration with appropriate others, adjusts the service plan based on changes in the patient's needs;
  • Conducts home visits on a regular basis and as needed in accordance with patient needs and organizational policies;
  • Counsels patients on placement process utilizing established criteria and guidelines for patients seeking placement, obtains consent, completes functional, psychosocial, medical and financial documentation;
  • Advocates for the patient to facilitate positive patient outcomes;
  • Determines the patient's continuing eligibility for services and provides counseling and referral to other providers/agencies when service is decreased or discontinued, or when additional outside agency support is required;
  • Conducts reassessments for patients awaiting placement;
  • Discharges patient from service and redirects to/facilitates alternative resources, if applicable and assists with access such services, if needed by the patient;
  • Promotes, educates and interprets the role and services of the South East CCAC to individuals, groups and community agencies, and health care partners;
  • Participates in data collection activities as required;
  • Assists with the orientation of new staff/students and carries out preceptor responsibilities as required;
  • Maintains confidentiality and privacy by safeguarding patient information in accordance with legislation, professional college standards and South East CCAC policy;
  • Initiates and maintains comprehensive service records for each patient;
  • Identifies and participates in ongoing professional development and staff education;
  • Performs other duties that may be assigned.


  • Follows safe work procedures;
  • Reports injuries and illnesses;
  • Plans and carries out work both internally and externally in a safe manner;
  • Abides by all legislative requirements, and related policies and procedures;
  • Participates in related training and development, e.g. WHMIS;
  • Maintains competency related to organization's Emergency Response Plan, e.g. participates in planned tests. Reports unsafe or unhealthy working conditions;
  • Is a 'competent person' as defined by the Occupational Health & Safety Act, and responsible for duties as outlined in the Occupational Health & Safety Act in section 27(1).


  • Committed to patient-focused care;
  • Proven ability to manage time effectively, i.e.  organize work, meet deadlines, set priorities, multi-task, and delegate effectively;
  • Effective interpersonal and communication skills;
  • Demonstrated leadership skills and proven ability to work effectively both as a member of a team and independently;
  • Proven assessment, goal-setting, problem-solving, decision-making, and crisis management skills;
  • Demonstrated commitment to maintaining cooperative and collaborative relationships with partners and colleagues;
  • Willingness to be flexible and facilitate change;
  • Proficient in working in a computerized environment.



  • Holds current appropriate unrestricted registration as a member of one of the following: the College of Nurses of Ontario, the College of Audiologists and Speech Language Pathologists of Ontario, the College of Occupational Therapists of Ontario, the College of Physicians and Surgeons of Ontario, the College of Physiotherapists of Ontario, the College of Psychologists of Ontario or is a member holding a certificate of registration as a Social Worker with the College of Social Workers and Social Services Workers of Ontario;
  • University degree preferred in Nursing, Physiotherapy, Occupational Therapy,   Speech Language Pathology, Social Work;
  • Experience in community practice engaged in either case management or multi-disciplinary approach to patient care is preferred;
  • Demonstrated computer literacy is required to facilitate the use of automated patient information systems;
  • Vehicle and valid Ontario driver's licence is required;
  • Ability to communicate effectively orally and in writing in both official languages (English and French) is considered as asset.
  • New and existing employees must have the ability to access applicable health care partner information systems as a condition of employment.

​Status: Full-time (permanent and temporary positions available)

Initial Hours of Work: Seventy (70) hours bi-weekly. Subject to all hours of operation as needed

Number of Positions to fill: Two (2)

Location: Kingston

Salary: $36.26 to $43.00 per hour

How to Apply: Applicants should submit resume and cover letter, indicating "Care Coordinator, Kingston" on or before September 22, 2016 to:


If you have any questions, please contact Jessie Burns, Recruitment Specialist at 1-888-871-8868 extension 5675.

"La version Française de cette annonce est disponible sur demande."

We thank all applicants for their interest, however, only those selected for an interview will be contacted. If you require a disability related accommodation in order to participate in the recruitment process, please notify Human Resources

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.