GAIN Nurse Care Coordinator

Are you an experienced registered nurse (RN) seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

The Geriatric Assessment and Intervention Network teams are specialized, inter-professional geriatric services providing comprehensive geriatric assessment and creating coordinated care plans with seniors and families to optimize function and independence and help to keep frail seniors living at home.

GAIN Nurse Care Coordinators are located in the GAIN hubs/clusters throughout the Central East region.

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 8,000 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 and work-life balance.

What will you do?

Working seamlessly as an integral part of the inter-professional team, the GAIN Nurse Care Coordinator uses his/her nursing expertise and system navigation skills to facilitate the creation and implementation of GAIN coordinated care plans using her/his full scope of practice in the assessment, planning, implementation, and evaluation of patient care needs. This includes the provision of intensive case management to GAIN patients through determination of client eligibility for In Home/Placement services, assessment of client care needs, planning, authorizing and coordinating of service delivery that best meet the needs of the patient, and monitoring patient response to therapeutic intervention.

GAIN Nurse Care Coordinators act within the mission, vision and values of Ontario Health atHome and the GAIN approach to care.

In addition, the GAIN Nurse Care Coordinator will facilitate transition of patients through the system, coordinating with other care partners including primary care providers and specialists. The successful incumbent will actively participate in care reviews; conduct RAI assessments; participate in comprehensive geriatric assessment, collaborative care plan development and conduct clinical assessments in both the GAIN Community hubs and patient’s home.

What must you have?

• A Registered Nurse (RN) with a relevant degree/diploma, currently licensed and registered with the College of Nurses of Ontario.
• 2+ years 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 driver’s 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 

Hours of work:

All hours of operation (Initially Monday-Friday 0830-1630; 70 hours per bi-weekly pay period) subject to change as per the Collective Agreement.

Position location and travel:

Regular travel within the geographical region of Ontario Health atHome Central East may be required. A valid Ontario driver’s license and access to a vehicle are necessary.

What do we offer?

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

• Attractive comprehensive compensation packages and benefits​
• Valuable development opportunities​
• Membership in a world class defined benefit pension plan​
• Salary: $41.92-$51.91/hour

Who we are

We are Ontario Health atHome, ready to serve every person in Ontario. Ontario Health atHome 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 you’re 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.

Date Posted: February 21, 2025

Closing Date: February 28, 2025

Job Type: Temporary Full-time

Start Date: March 17, 2025

Anticipated End Date: September 5, 2025

Program: Community

Branch: Scarborough

Group: ONA