Clinical Coordinator, Acute@Home - Temporary Full Time

Southlake Health Community; Newmarket; Hybrid; CAD 89,000 - 106,000; Full time

Benefits offered by this job

Hybrid/virtual/in-person option

Health and dental benefits

HOOPP pension

Wellness initiatives

Job summary

Southlake Health is seeking a Clinical Coordinator to identify and screen patients for Acute Care @ Home, coordinating referrals, intake, consent and admission processes. You will educate patients and families, arrange transfers, and ensure necessary medications and equipment are in place.

Close collaboration with hospital and community teams is essential. The role emphasizes program data collection, performance monitoring, and ongoing care coordination to support safe, timely transitions from

Qualifications

• Bachelor of Science in Nursing (BScN) required.
• Current Registered Nurse (RN) registration in good standing with the College of Nurses of Ontario.
• Minimum two (2) years of discharge planning and care coordination experience in acute care.
• Minimum two (2) years of experience in @Home or hospital-to-home or similar program.

Responsibilities

• Identify and screen patients eligible for Acute Care @ Home.
• Coordinate referral intake consent and admission processes.
• Educate patients and families about the program and readiness for home care.
• Coordinate transfer planning and ensure medications and equipment are arranged.
• Facilitate communication between hospital and community teams.
• Maintain accurate documentation and track program metrics.
• Support program evaluation and quality improvement.

Skills

Clinical coordination

Discharge planning

Care coordination

Patient flow

Communication

Time management

Documentation

Data collection

Team collaboration

Education

BScN

RN in good standing

Job description

Job Category: Leadership

Hospital Location: Newmarket ON

Job Type: Temporary (Fixed Term), Full time

Number of Positions: 1

Minimum - Maximum Hourly Rate: $64.94 - $77.20

Why Join Our Team?

• A people-first workplace environment that prioritizes belonging, wellness, and psychological safety.

• Hybrid, virtual, and in-person working environment (where applicable).

• Progressive health and dental benefit plans.

• HOOPP pension plan with employer and employee premium sharing.

• Enhanced wellness initiatives, including virtual fitness classes and on-site gym memberships.

About the role:

The Clinical Coordinator is responsible for identifying, screening and coordinating patients who continue to require hospital-level acute care but can be safely managed at home through the Acute Care @ Home program.

The Clinical Coordinator supports the entire patient journey from identification and referral through screening, intake, consent, eligibility assessment, transfer home, active care, discharge and transition. Working closely with patients, families, physicians, and interdisciplinary teams, the Clinical Coordinator ensures safe, timely, and coordinated movement through the program.

This role also supports program evaluation through accurate documentation, data collection, and monitoring of key performance indicators.

What you bring:

• Bachelor of Science in Nursing (BScN) required.
• Current Registered Nurse (RN) registration in good standing with the College of Nurses of Ontario.
• Minimum two (2) years of recent discharge planning and care coordination experience within an acute care hospital setting.
• Minimum two (2) years of experience working within an @Home, hospital-to-home or comparable acute/transitional care program.
• Strong knowledge of acute care patient flow, discharge planning, transitions of care and community-based services.
• Demonstrated experience with patient identification, screening, intake, eligibility assessment and transition planning.
• Demonstrated ability to coordinate complex patient transitions from hospital to home.
• Strong clinical assessment, critical-thinking, problem-solving and decision-making skills.
• Excellent communication and interpersonal skills with the ability to collaborate effectively with patients, families, physicians and interdisciplinary teams.
• Strong organizational and time-management skills with the ability to manage multiple referrals and competing priorities.
• Demonstrated ability to work independently and make timely decisions in a fast-paced environment.
• Strong electronic documentation, computer and data collection skills.
• Experience collecting, monitoring and reporting program metrics and key performance indicators.
• Demonstrated commitment to patient- and family-centered care, patient safety, quality improvement and teamwork.

What you’ll be doing:

• Proactively identifies and screens patients who may be eligible for Acute Care @ Home.
• Reviews referrals and completes clinical eligibility assessments in collaboration with the interdisciplinary team.
• Coordinates patient referral, intake, consent and admission processes.
• Educates patients and families about the program and confirms their readiness and suitability for care at home.
• Coordinates transfer planning, ensuring required medications, equipment, diagnostics and clinical services are arranged.
• Facilitates timely communication and clinical handover between hospital and community teams.
• Acts as a key liaison between patients, families, physicians and interdisciplinary care providers.
• Coordinates individualized care plans and addresses barriers that may delay transfer home.
• Monitors patient progression through the program and supports ongoing care coordination.
• Identifies clinical or operational concerns and escalates appropriately to the Acute Care Charge Nurse and/or most responsible provider.
• Initiates discharge planning early and coordinates timely transition once hospital-level acute care is no longer required.
• Ensures appropriate follow-up services and clinical handover are arranged at discharge.
• Maintains accurate and timely documentation throughout the patient’s episode of care.
• Collects, validates and tracks program data and key performance indicators, including referrals, eligibility, admissions, length of stay, escalations, discharge outcomes and other required metrics.
• Supports program evaluation, quality improvement and identification of opportunities to improve patient flow and outcomes.
• Participates in the development and refinement of clinical pathways, workflows and processes for the Acute Care @ Home program.
• Performs other duties as assigned by the Manager or delegate.

Southlake Health is fully committed to a culture of belonging and an inclusive environment that encourages every team member to lead within their role, generate innovative ideas that reinforce our mission and goal to create a healthy workplace where our community can thrive.

Regular and reliable attendance is an expected requirement of this position.

We are committed to a selection process and work environment that is inclusive and barrier-free. Accommodation will be provided in accordance with the Ontario Human Rights Code. Applicants who may require accommodation during the selection process are encouraged to notify the Human Resources Department when contacted for an interview. The People, Culture and Experience team will work together with the hiring committee to arrange reasonable and appropriate accommodation for the selection process, which will enable you to be assessed fairly and equitably.

Use of Artificial Intelligence (AI)

We prioritize a people-first workplace culture which emphasizes equity and inclusion throughout our hiring process. To ensure fairness and transparency, all applications are reviewed and assessed by our dedicated team of recruiters and hiring managers, not by artificial intelligence (AI). We value the unique perspective each candidate brings to our organization.

Health & Safety Workplace Responsibilities

It is the responsibility of all Southlake Health employees to work safely and promote health and safety in the workplace. Employees must adhere to the duties of workers, as stipulated in Section 28 of the OH&S Act, as well as all Southlake OH&S policies and procedures. Must be able to perform all necessary bona fide duties for the position, as outlined in the position guide. Must review and be capable of performing duties as outlined in the Job Demands Analysis for the position as a condition of offer. Proven ability to attend work regularly as per the Attendance Support Policy.

Commitment to Diversity and Inclusion

Southlake Health is fully dedicated to employment equity, diversity, and inclusion in our recruitment practices. We welcome candidates who identify with equity-seeking groups, including women, racialized individuals, Indigenous Peoples, persons with disabilities, and those from the 2SLGBTQ+ community. Any information provided will be kept confidential and used appropriately in our recruitment process.

Anti-Oppression/Anti-Racism at Southlake Health

Southlake Health is committed to having a workforce that is reflective of the diversity of York Region and strongly encourages applications from all qualified individuals, and from those who can provide different perspectives and contribute to a further diversification of ideas.

Only candidates selected for an interview will be contacted. Thank you for your submission. We appreciate your interest in joining Southlake Health!