Transitions Care Lead

SE Health; Golden Horseshoe; Hybrid; CAD 69,000 - 87,000; Full time

Benefits offered by this job

Total rewards package

Hybrid work

Tuition support

Car-loan & housing assistance

Exclusive staff perks

Job summary

SE Health in Ontario is seeking a Transitions Care Lead to oversee care flow between hospital partners and community teams, ensuring high-quality client care and meeting program objectives. You will collaborate with hospitals for smooth home transitions and contribute to performance improvements.

The role emphasizes managing referrals, care planning, and monitoring outcomes within the Acute Transition programs, and involves on-call duties as needed.

Qualifications

• 3+ years of experience in community health or related field.
• Knowledge of the health care delivery system including hospital discharge planning.
• Strong case management and coordinating care within interdisciplinary teams.
• Excellent assessment, decision-making and critical thinking skills.
• Excellent interpersonal communication and presentation skills with diverse stakeholders.
• Advanced MS Office skills and comfort with new technologies.

Responsibilities

• Act as the primary point of contact for the hospital navigator/coordinator.
• Receive, monitor and update the client tracking/notification/flow tools.
• Receive, review, and accept referrals for in-home transition services.
• Coordinate with hospital navigator/coordinator and SE @Home Team.
• Participate in hospital discharge care conferences for complex clients.
• Prepare initial care plan and place initial equipment/supplies orders.
• Monitor program metrics and report risk-related events.
• On-call as required for program support.

Skills

Case management

Interdisciplinary teamwork

Communication skills

Decision making

Time management

Critical thinking

Self-directed

Patient care

Driver's license

Adaptability

Education

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Microsoft Visio

Job description

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.

Why join our team?

• Competitive Total Rewards So much more than a paycheque! Enjoy comprehensive benefits, pension, flexible pay options, car-loan support, housing solutions and exclusive staff perks.
• Flexibility & Belonging Thrive with hybrid work, flexible scheduling and a supportive, inclusive culture that puts people first.
• Purpose & Impact Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada.
• Growth That Meets Your Ambition Access tuition support, training and meaningful career pathways across a growing, future-focused organization.

Position Summary

As the Transitions Care Lead You will provide exemplary leadership and care flow management between the hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives. This exciting position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client’s home environment. Additionally this position will help to ensure performance targets are met and be involved in quality improvement initiatives as it relates to optimizing patient flow and management processes within the Acute Transition programs.

Responsibilities

• Act as the primary point of contact for the hospital navigator/coordinator
• Receive, monitor and update the client tracking/notification/flow tools
• Receive, review, and accept referrals for in-home transition services
• Coordinate/Liaise with hospital navigator/coordinator and SE @home Team as required.
• Participate in hospital discharge care conference for complex clients as required
• Prepare an initial care plan (e.g. for 48-72 hours post transition) and place an initial equipment and supplies order as required
• Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE @Home Team
• Attend program huddles with hospital (as per contract requirements)
• Monitor and communicate significant deviations from the care plan to the hospital as required.
• Communicate to the hospital any risk-related events
• Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital(required in contract)Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
• Facilitate risk management as per established policies and procedures
• Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings
• Participate in program evaluation and process improvement
• On-call as required for programs support
• Other duties to ensure program is running smoothly

Requirements

• Membership, in good standing, with the applicable regulatory body:
• College of Nurses of Ontario.
• College of Physiotherapists of Ontario.
• College of Occupational Therapists of Ontario.
• Ontario College of Social Workers and Social Service Workers.
• 3+ years of recent experience in community health or a related field.
• Knowledge of the health care delivery system including hospital discharge planning, community care and support services
• Excellent skills in case management and coordinating care within interdisciplinary teams
• Excellent assessment and decision-making skills
• Passion for excellent customer service and customer experience
• Demonstrates strong critical thinking, problem-solving and self-directed skills.
• Excellent interpersonal communication, and presentation skills with a diverse group or stakeholders (hospital partners, front line staff, management team)
• Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community).
• Advanced s k ills in M ic r o s o f t Off i ce (Word, Excel, PPT, Visio) and comfort with learning/working with new and emerging technologies (e.g. remote patient monitoring/virtual care technologies, EHR systems, reporting systems)
• A valid driver’s license and access to a reliable vehicle.

About SE Health

SE Health is a not-for-profit social enterprise advancing health with heart. With 115+ years of impact, we bring hope, happiness and exceptional care to people and communities across Canada. We lead with empathy, dignity and purpose while building a future where everyone can realize their full health and well-being potential. We’re also an inclusive, supportive workplace offering competitive compensation, strong benefits and real opportunities to grow. We’re All In Together.

Accessibility

If you require accommodations due to illness or disability, please contact Talent Acquisition at [e-mail].

AI And Compensation Details

We use AI to take notes during our interview. All applications and interviews are reviewed by our Talent Acquisition team. This role is a replacement position. The hiring pay range is $69 000.00 - $87 000.00 per annum based on experience.