Continuing Care Coordinator, Home and Community Care - Permanent Full-Time (1.0)

cheo; Ottawa; On-site; CAD 63,000 - 79,000; Full time

Job summary

CHEO in Ottawa is seeking a Care Coordinator to deliver connected, patient-centred care for children and youth in the community. You will perform comprehensive assessments, care planning, and evaluation of home and school care services, coordinating with families, clinicians, and community agencies post-discharge and for ongoing needs.

The role emphasizes family-centered, culturally sensitive care, multidisciplinary collaboration, and evidence-informed practice, with accountability for

Qualifications

• Membership in good standing with the applicable regulatory body is essential.
• Current registration with the appropriate regulatory College is essential.
• Two years of related professional experience is essential.

Responsibilities

• Conduct comprehensive assessment and re-assessments of children and youth in the community.
• Develop, implement, and evaluate individualized care plans with patients and families.
• Determine service eligibility and coordinate referrals for home/school care.

Skills

Effective communication

Team collaboration

Time management

Independent work

Education

Registered professional (Nursing/OT/Physiotherapy/SLP/Social Work/Dietetics)

Job description

Compensation Pay Range: $46.02-$56.91

Ottawa is built on un-ceded Algonquin Anishinaabe territory. The peoples of the Algonquin Anishinabek Nation have lived on this territory for millennia and we honour them and this land. Their culture and presence have nurtured and continue to nurture this land. CHEO also honours all First Nations, Inuit and Métis peoples and their valuable past and present contributions to this land.

CHEO is one of the few stand-alone, global leaders in pediatric health and is home to more than 6,500 staff, clinicians, scientists and researchers, as well as volunteers - all of whom work together to help children and youth achieve their best lives. Within its own walls and through partnerships with community providers, CHEO has transformed from a 20th century acute care hospital into a 21st century integrated child and youth health system.

Ranked in the top 1% of Canadian hospitals for the digitization of its clinical infrastructure, CHEO combines excellence in clinical care, research, and education to advance seamless care that's provided where, when, and how it is needed. CHEO's Research Institute is dedicated to world-class clinical, translational, and basic science research covering a wide range of children's health concerns. CHEO has been named Canada's best health-care employer by Forbes in 2024, 2025 and 2026 and is ranked second among Canadian hospitals on its list of Canada's Best Employers for multiple consecutive years. For the 14th consecutive year in a row, the editors of Canada's Top 100 Employers has recognized CHEO as a top employer in the National Capital Region. Every year CHEO helps more than 500,000 children and youth from Eastern Ontario, western Quebec, Nunavut and Northern Ontario.

POSITION SUMMARY

As a Care Coordinator supporting children and youth in the community, you will play a critical role in delivering connected, accessible, and patient-centred care for them and their families. This role focuses on conducting comprehensive assessments and re-assessments, care planning, implementation, and evaluation of home and school care services. You will work closely with patients, caregivers, interdisciplinary health care teams, and community agencies to ensure timely and appropriate services following discharge from CHEO and for those with ongoing community care needs. This position is grounded in a commitment to family-centered, culturally sensitive care, multidisciplinary collaboration, and evidence-informed practice. You will be responsible for determining service eligibility, coordinating care, and facilitating referrals to support children and youth at home.

MAIN RESPONSIBILITIES

• Conduct comprehensive assessment and re-assessments of children and youth to determine home and school care needs in the community.
• Develop, implement, and regularly evaluate individualized care plans in collaboration with patients, families, and care teams.
• Support safe and effective transitions from hospital to home by collaborating with CHEO teams, families, and service providers.
• Determine eligibility for home and school care services based on established guidelines and clinical judgement.
• Maintain ongoing communication with patients, families, interdisciplinary teams, and service providers to monitor progress and adjust care plans as needed.
• Completes documentation and maintains appropriate EPIC and CHRIS patient records in accordance with the employee's respective regulatory College and CHEO policies and procedures.
• Attends and participates actively in team meetings and general staff meetings.
• Assumes responsibility for maintaining professional knowledge and updated skills.
• Will support other duties as assigned.

QUALIFICATIONS

• Membership in good standing, with the applicable regulatory body: Nursing (RN), Physiotherapy, Occupational Therapy, Speech-Language Pathology, Social Work or Dietetics (Essential)
• Current registration with the appropriate regulatory College (Essential)
• At least two (2) years of related professional experience (Essential)
• Related experience in a community-based setting (Preferred)
• Demonstrated competency in assessment of pediatric health care needs (Essential)
• Knowledge of medical diagnoses and prognoses, symptom management, and cognitive/psychiatric disorders (Essential)
• Awareness of and sensitivity to the needs of a culturally diverse population (Essential)
• Communicates effectively, orally and in writing (Essential)
• Demonstrates excellent in interpersonal skills (Essential)
• Excellent time management and organizational skills (Essential)
• Works effectively in both a team environment and independent