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Care Coordinator – Integrated Comprehensive Care (ICC)(x3.0 FTEs)

Closing Date:
Open until position filled
Job Summary:

​Initial Assignment:       St. Mary’s General Hospital; Regular Day Shift.


Reporting to the Manager of Patient Services, the incumbent will be responsible for:

  • Engaging the client by establishing a committed relationship; to work with the client in addressing his or her needs and goals;
  • Assessment of referred clients to obtain information in order to identify a client's functional & cognitive status, strengths, values, abilities, preferences, resources, supports and needs; using standardized tool.
  • Determination of eligibility for services or programs based on legislation, standards, regulations & policies;
  • Provide patient centered care coordination, education and system navigation to a select group of patients
  • Development of service plans, with goals that are based on problems/needs, in collaboration with the patient/Substitute Decision Maker, inter-professional team, support networks, community agencies and a variety of formal and informal supports, utilizing information from the assessment, legislation, standards, regulations and policies, and with consideration given to the allocation of resources required to meet goals;
  • Coordinates seamless care transitions ensuring all health providers are aware of changes in health status and plan of care;
  • Implementation of the service plan, including communication and evaluation to ensure that the service plan is being carried out as planned;
  • Responsible for clinical education related to respective health conditions and to enhance patient's self-management abilities and skills;
  • May provide medical advice to patients within scope of practice in hospital and community and work with the medical provider to problem solve issues; link to primary care and specialists with recommended testing/treatment and monitor outcomes related to interventions alongside the inter-professional team and ensuring reporting back to prescriber;
  • Planning for discharge or care transition once the identified goals and outcomes have been achieved;
  • Alternate planning for non-eligible patients and provide program interpretation/education to hospital, community agency staff, physicians and other partners in the health and social system.
  • Provides advice, guidance, advocacy and supportive counselling to clients related to options and services, including placement to long-term care facilities;
  • Maintains confidentiality of client records;
  • Documents according to LHIN and professional college standards of documentation.
  • Participation in program development/research and professional development;
  • Working in a multi-disciplinary team and promoting positive working relationships;
  • Takes all reasonable steps to ensure a healthy and safe work environment and participates in continuous quality improvement.
  • Other duties as required.


  • RN designation required. 
  • Preference for the surgical streams will be given to individuals with education and skills related to acute care and surgical care experience with cardiac, lung, thoracic and esophagectomies. Further experience with chronic disease COCPD and CHF is preferred. 
  • Preference for Orthopedic streams will be given to individuals with education and skills related to orthopedic and wound care knowledge.  Experience with hip and knee surgery rehabilitation preferred.  (RN or Therapy designation required). 
  • Adult learning principles preferred.
  • Three years of relevant recent direct care experience in required profession.
  • Proficient in the operation of a personal computer in a networked environment using a variety of computer software and data entry skills, i.e. Excel, Data Base Software, as well as various other programs.
  • Knowledgeable in the use of technology in a community setting – e.g., lap top in the home, Smart Phone, remote networking, etc.
  • Demonstrated experience in comprehensive assessment, use of different or combined approaches.
  • Demonstrated skills in synthesizing information in order to plan and adjust services and to assist clients with informed decision-making.
  • Demonstrated skill in crisis management and risk situations.
  • We require analysis and critical thinking related to service authorization, care planning and management of budget for the caseload.
  • Knowledge of care coordination principles and practices;
  • Knowledge of LHIN policies & procedures, legislation & regulations;
  • Knowledge of community resources, services and the roles of health professionals/support workers;
  • Knowledge of prevention and health promotion.
  • Demonstrated skills in interviewing, public relations and conflict resolution.
  • Demonstrated skill in establishing rapport, managing good working relationships, and negotiating issues with clients, families and other team members, both internal and external to the organization.
  • The ability to travel throughout Waterloo Region and Wellington County is required.
  • Fluency in French language preferred.

This position may be required to provide relief at other LHIN locations or teams as needed and may be part of the on call rotation as per the provisions of the ONA collective agreement.

WWLHIN strives to create a respectful, accessible and inclusive work environment.  Upon individual request, hiring processes will be modified to remove barriers to accommodate those with disabilities.  Should any applicant require accommodation through the application, interview or selection processes, please contact Human Resources at HR.WW@lhins.on.cafor assistance. 

If you are interested in this position, please submit a cover letter, along with a detailed resume, outlining how your skills, qualifications and experience meet the position requirements, quoting posting #17/0/73 before 4:30 p.m. on December 6, 2017 to Human Resources (e-mail: We thank all applicants in advance; however, we will be communicating only with those selected for an interview.

 *** PLEASE NOTE*** Cover letters and resumes need to be submitted as a single file, acceptable files are: doc, docx, and pdf. Please include your first name, last name and job title in the file name when applying, example JohnSmith_AdministrativeAssistant.


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.