Clinical Care Coordinator, eRehab

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

As a Clinical Care Coordinator, you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health care practitioners. 

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 9,000 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.

Reporting to the Patient Services Manager, the Clinical Care Coordinator is responsible for providing a “hands-on” and an “in-home” support approach for patients who are being discharged from acute care and require in home therapy. The Clinical Care Coordinator will provide patients with timely communication and linkage to community rehabilitation therapy based on the evidence informed practice for specific disease management. The patient diagnosis/surgery will include mild and  moderate stroke and deconditioned adults being discharged from Hospital. Some (TKA) and (THA) patients may also be on program. 

As an integral part of an interdisciplinary team, the Clinical Care Coordinator will develop service plans to assist patients as they recover from their acute illness or orthopedic surgery. Expected outcomes are reduced acute care length of stay, emergency and hospital admissions and access to timely rehabilitation. The Clinical Care Coordinator will provide timely in-home nursing visits as required and coordinate the first interdisciplinary team visit within 72 hours from hospital discharge. The Clinical Care Coordinator will conduct a comprehensive nursing assessment, medication reconciliation using a patient centered focus and will work with the patient and their support to develop a coordinated service plan.                 

What will you do?

• In collaboration with patients and their families, assess care needs, determine eligibility for services, and develop individual care and service plans
• Link patients with service providers
• Coordinate and monitor care plan delivery
• Establish a helping relationship with patients and their families
• Balance patient needs and choices with available resources, ensuring patients’ values and preferences are respected

What must you have?

• Membership, in good standing, with the applicable regulatory body:
• College of Nurses of Ontario (RN, BScN)
• 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, prioritizion 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

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: $40.23/hr to $52.80/hr

What do I need to know?

Anticipated Start Date: January 12, 2026

Status: Temporary Full-Time (approximately 14 months)
Hours of work: 8:30am-4:30pm - Monday to Friday
Site: Chatham-Kent Health Alliance with a home office in the Chatham branch. Travel to Sarnia will be required to assist with the Sarnia case load.

Posting Expiry: December 16, 2025
Unionized Position - This is not a remote position. Erehab Clinical Care Coordinators work in person at their site. Travel to Sarnia is required for this position.

Who we are

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

This job posting is for an existing vacancy.