Transitional Care Case Manager

Grand River Hospital; Kitchener; On-site; CAD 65,000 - 90,000; Full time

Job summary

Waterloo Regional Health Network (WRHN) is seeking a Transitional Care Case Manager to coordinate discharge planning and care transitions within an interdisciplinary team. This regulated healthcare professional will lead discharge planning from admission and partner with hospital and community services.

Responsibilities include identifying high-risk discharges, coordinating referrals, and ensuring timely follow-up.

Qualifications

• Bachelor’s or Master’s Degree in a regulated healthcare related discipline (Registered Nurse, Occupational Therapy, Physiotherapy, Master of Social Work)
• Member in good standing of a professional college
• Extensive knowledge of healthcare systems, discharge planning, and community resources.
• Excellent communication, leadership, and problem-solving skills.
• Proficiency in Cerner or equivalent electronic health record systems.
• Minimum three to five years of recent acute care hospital and community experience
• One year experience in case management, utilization review or equivalent
• Proven ability to lead interdisciplinary teams in system-wide quality improvement initiatives
• Advanced clinical assessment, decision-making, and problem-solving skills
• Excellent communication and interpersonal skills, with the ability to engage and influence various stakeholders
• Strong project management and organizational skills to support multiple initiatives
• Commitment to patient-centered, equitable, and high-quality care
• Computer proficiency (Microsoft Word, MS Teams, e-mail, etc.)
• Good attendance record.

Responsibilities

• Discharge Planning and Coordination: Initiates discharge planning at admission, completes interprofessional assessment within 48 hours for high-risk patients, establishes Estimated Date of Discharge (EDD) with MRPhysical.
• Develops individualized discharge plans, shared with patients and families at least 48 hours prior to discharge.
• Ensures referrals to community partners (OHaH, Community Support Services, H2H, Paramedicine, etc.).
• Risk Identification and Assessment: Screens admissions within 24 hours to identify high-risk discharges; document pre-admission functional status, demographics, caregiver supports, and barriers.
• Interdisciplinary Collaboration: Collaborates daily with MRPs, Occupational and Physiotherapist, Resource Person and Social Worker; participates in rounds and case conferences.
• Communication and Documentation: Communicates discharge plans clearly; maintains accurate documentation in Cerner; participates in MSRD rounds and tracks length of stay metrics; schedules follow-up with Primary Care Physician within 1–7 days.
• System Navigation and Advocacy: Coordinates with Ontario Health at Home case managers and external agencies; educates patients and families on resources.
• Monitoring and Continuous Improvement: Monitors extended stays; participates in MSRD rounds; tracks MSRD and ALC designation data.
• Leadership and Education: Provides leadership to care team; promotes Home First philosophy through collaboration, education, and advocacy.

Education

Bachelor’s or Master’s Degree in a regulated healthcare related discipline

Job description

Welcome to health care that soars above. Welcome to WRHN.

Internal candidates should apply through our intranet site (Lotus Link). Check the staff perks and benefits page on Lotus Link for more information.

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Job Summary:

Position: Transitional Care Case Manager

Category: Administrative

Employment Type: Employee

Post Date: 10/15/2026

Salary: Negotiable

Close Date: 10/22/2026

Location: CA:ON:Kitchener

Invalid Address

911 Queen's Blvd,Kitchener,ON,N2M 1B2,CA

Transitional Care Case Manager (Job ID: 7129)

Transitional Care Case Manager - Temporary Full Time - until Approximately October 2027.

This is for an existing vacancy.

Location: WRHN

Home to seven regional programs and comprehensive health-care services, Waterloo Regional Health Network (WRHN, pronounced wren) is committed to meeting the current and emerging needs in Waterloo-Wellington and beyond.

WRHN is redefining the health-care experience through collaboration and innovation, addressing barriers to access, advancing care delivery, and setting new standards in compassionate, empowered community-driven health care.

At WRHN, every patient is at the centre of everything we do as we strive to improve lives, inspire healing, and build healthier, stronger communities. By listening to patients and partners, we strive to connect communities to the right care, at the right place, and at the right time.

Please Note: New employees must provide documentation/proof of COVID-19 vaccination status, a 2-step TB test, as well as proof of immunity to measles, mumps, rubella, and varicella (chickenpox) prior to their start date at Waterloo Regional Health Network (WRHN). New Employees will require clearance from Employee Health, Safety and Wellness before they are able to begin any position within WRHN.

Position Summary

The Transitional Care Case Manager is a regulated healthcare professional who plays a central role in coordinating safe, timely, and effective discharge planning and care transitions. Operating within an interdisciplinary team, the Transitional Care Case Manager enhances patient outcomes, ensures continuity of care, and supports optimal utilization of health resources through active collaboration with patients, families, hospital teams, and community partners.

This role is aligned with Ontario Health’s Home First philosophy and best practices in Alternate Level of Care (ALC) management. The Transitional Care Case Manager acts as a clinical leader in discharge planning, proactively identifying patient needs and barriers early in the care journey.

Responsibilities

Discharge Planning and Coordination

• Initiates discharge planning at admission, including completing a comprehensive interprofessional assessment within 48 hours with patients identifies as high risk as being designated ALC.
• Establishes and communicates an Estimated Date of Discharge (EDD) in collaboration with the Most Responsible Physician.
• Develops individualized discharge plans, shared with patients and families at least 48 hours prior to discharge.
• Ensures appropriate referrals to community partners, including but not limited to Ontario Health at Home (OHaH), Community Support Services, Hospital-to-Home (H2H) program, Paramedicine team etc.

Risk Identification and Assessment

• Screens all admissions within 24 hours to identify high-risk discharges using standardized assessment tools.
• Gathers and documents pre-admission functional status, demographic data, caregiver supports, and barriers to discharge.

Interdisciplinary Collaboration

• Collaborate daily with the interprofessional team, including the Most Responsible Physician (MRP), Occupational and Physiotherapist, Resource Person and Social Worker to maintain and revise discharge plans.
• Participates in interprofessional discharge rounds and case conferences to address care needs, services coordination, and planning.

Communication and Documentation

• Clearly communicates discharge plans to patients, families, and the care team.
• Maintains accurate documentation in Cerner and other relevant systems.
• Attends and contributes to bullet rounds, tracking and addressing MSRD and ALC and length of stay metrics.
• Ensures follow-up appointments with Primary Care Physician are scheduled within 1–7 days.

System Navigation and Advocacy

• Coordinates with Ontario Health at Home case managers and external agencies to ensure seamless post-discharge support.
• Educates and assists patients and families in understanding and accessing community resources.

Monitoring and Continuous Improvement

• Monitors extended stays and proactively address barriers to discharge.
• Participates in Medically Stable Ready for Discharge (MSRD) rounds and strategy sessions for complex or prolonged cases.
• Tracks and reports relevant data including MSRD and ALC designation.

Leadership and Education

• Provides leadership and guidance to the care team to ensure patients experience seamless transitions through the healthcare continuum.
• Acts as a resource for discharge planning best practices.
• Promotes the Home First philosophy through collaboration, education, and advocacy.

Position Requirements

• Bachelor’s or Master’s Degree in a regulated healthcare related discipline (Registered Nurse, Occupational Therapy, Physiotherapy, Master of Social Work)
• Member in good standing of a professional college
• Extensive knowledge of healthcare systems, discharge planning, and community resources.
• Excellent communication, leadership, and problem-solving skills.
• Proficiency in Cerner or equivalent electronic health record systems.
• Minimum three to fiveyears of recent acute care hospital and community experience
• One year experience in case management, utilization review or equivalent
• Proven ability to lead interdisciplinary teams in system-wide quality improvement initiatives ;
• Advanced clinical assessment, decision-making, and problem-solving skills;
• Excellent communication and interpersonal skills, with the ability to engage and influence various stakeholders;
• Strong project management and organizational skills to support multiple initiatives;
• Commitment to patient-centered, equitable, and high-quality care ;
• Computer proficiency (Microsoft word, MS Teams, e-mail, etc.);
• Good attendance record.

International Applicants

If you are seeking employment on a temporary work or study permit we recommend reviewing work permit restrictions as it applies to healthcare organizations in Canada. Individuals holding a work or study permit seeking employment in the healthcare sector may be required to complete additional steps in the process. This may also apply to current employees seeking renewal of their work permits. It is the accountability of the applicant and/or employee to ensure they are adhering to their specific work permit restrictions.

We would like to thank all candidates in advance for their interest and only those candidates selected for an interview will be contacted. Due to the volume of applications, we receive, we are unable to confirm the receipt of individual applications or resumes.