Clinical Care Coordinator, eRehab

Are you an experienced registered nurse (BScN) seeking a rewarding career that cares for others in a professional practice that cares for you Youre looking in the right place.

As a Clinical Care Coordinator you will assess and determine patient care needs and eligibility provide accessand referrals to community services and engage with patients caregivers and other health care practitioners.

Whether you work in our office in the community or a health care facility you will play a lead role in providing connected accessible patient-centred care and be supported by our collaborative team that includes over 9000 regulated health care and other professionals.

As a valued team member your mission will be to help our patients be healthier at home while you benefit from our supports for professional growth personal wellness andwork-life balance.

Reporting to the Patient Services Manager the Clinical Care Coordinatoris responsible forproviding a hands-on and an in-home support approachfor patients who are beingdischarged from acute care andrequire inhome therapy. The Clinical Care Coordinator will provide patients withtimelycommunication and linkage to community rehabilitation therapy based on the evidence informed practiceforspecificdiseasemanagement.Thepatient diagnosis/surgerywillincludemildandmoderate stroke and deconditioned adults being discharged from Hospital. Some (TKA) and (THA) patients may also be on program.

As an integral part of an interdisciplinary team the Clinical Care Coordinator will develop service plans toassistpatients as they recover from their acute illness or orthopedic surgery.Expectedoutcome isreduced acute care length of stay emergency and hospital admissions and access totimelyrehabilitation. The Clinical Care Coordinator will providetimelyin-home nursing visits as required and coordinatethefirstinterdisciplinaryteamvisitwithin72hoursfromhospitaldischarge.TheClinicalCare Coordinatorwillconductacomprehensivenursingassessmentmedicationreconciliationusingapatient centeredfocusandwillworkwiththepatientandtheirsupportstodevelopacoordinatedserviceplan.

What will you do

• In collaboration with patients and their families assess care needs determine eligibility for services and develop individual care and service plans
• Link patients with service providers
• Coordinate and monitor care plan delivery
• Establish a helping relationship with patients and their families
• Balance patient needs and choices with available resources ensuring patients values and preferences are respected

What must you have

• Membership in good standing with the applicable regulatory body:
• College of Nurses of Ontario (RN BScN)
• 2years of recent experience in community health or a related field
• Knowledge of the health care delivery system and community resources
• Excellent interpersonal communication assessment problem-solving and decision-making skills
• Effective time management prioritization and organizational skills with the ability to work independently and co-operatively in a busy multidisciplinary environment
• Established ability to accurately complete required documentation reports and forms
• A valid drivers licence and access to a reliable vehicle
• Proficient in a Windows environment
• We have a mandatory COVID-19 vaccination policy. As a condition of employment all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge

• Experience working with diverse patient groups e.g. multicultural homeless palliative acquired brain injury (ABI) mental health geriatrics pediatrics
• Case management experience or recent related community experience
• Ability to speak French or another second language

What do we offer

We know wellness is supported with work-life balance.In an inclusive culture committed to support your passion for continuouslearning growth and innovation we offer:

• Attractive comprehensive compensation packages and benefits
• Valuable development opportunities
• Membership in a world class defined benefit pension plan
• Salary: $40.23/hr to $52.80/hr

What do I need to know

Anticipated Start Date: January 12 2026

Status: Temporary Full-Time (approximately 14 months)
Hours of work: 8:30am-4:30pm - Monday to Friday
Site: Chatham-Kent Health Alliance with a home office in the Chatham branch. Travel to Sarnia will be required to assist with the Sarnia case load.

Posting Expiry: December 16 2025
Unionized Position - This is not a remote positions. Erehab Clinical Care Coordinators work in person at their site. Travel to Sarnia is required for this position.

Who we are

We are Ontario Health atHome ready to serve every person in Ontario.We partner with patients and caregivers primary care providers hospitals long-term care and retirement homes service providers and Ontario Health Teams to deliver responsive accessible integrated patient-centred care.

If youre interested in driving excellence in care and service delivery and seeking an unparalleled opportunity to lead and learn partner and connect care and be cared for this is your home.

Equity Inclusion Diversity and Anti-Racism Commitment

Ontario Health atHome is committed to a culture of equity inclusion diversity and anti-racism. We are committed to attracting engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

We thank all applicants for their interest; however only those selected for an interview will be contacted.

This job posting is for an existing vacancy.