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About the role

  • Clinical Services Coordinator guiding Canadians with vision loss from hospital to home rehabilitation. Coordinating assessments, care transitions, community supports, and client advocacy.

Responsibilities

  • Serve as the primary point of contact for clients referred to the Hospital-to-Home Program
  • Lead intake, needs assessment, service planning, and coordination of supports from hospital to community-based rehabilitation
  • Conduct intake, needs, and risk assessments
  • Develop and monitor individualized service plans
  • Prioritize referrals and identify safety or psychosocial concerns
  • Establish baseline outcomes and monitor client progress
  • Coordinate admission to VLRC services and timely rehabilitation supports
  • Collaborate with hospitals, healthcare providers, community organizations, and referral partners on integrated transition plans
  • Assess discharge readiness, support systems, living circumstances, and service requirements
  • Act as liaison among clients, families, healthcare professionals, and rehabilitation teams
  • Facilitate communication, problem-solving, shared care planning, case conferences, and interdisciplinary meetings
  • Support clients and families in navigating healthcare and community systems and advocate for appropriate services
  • Document client interactions, assessments, service plans, outcomes, and follow-up activities
  • Monitor service delivery metrics and rehabilitation outcomes
  • Coordinate follow-up activities, resolve outstanding service needs, and support planned case closures
  • Identify and escalate clinical, psychosocial, accessibility, and service-related risks
  • Contribute to program evaluation, quality improvement, and outcome measurement
  • Analyze trends, service gaps, and system barriers and recommend improvements
  • Foster partnerships through education, consultation, and outreach
  • Support development of hospital-to-home programs, referral pathways, and service delivery models
  • Perform other duties as required

Requirements

  • Experience coordinating care and services for individuals with complex health, rehabilitation, or psychosocial needs
  • Advanced care coordination and case-management skills
  • Strong assessment, problem-solving, and clinical judgment skills
  • Ability to manage multiple clients, competing priorities, and timelines in a fast-paced healthcare or community setting
  • Exceptional relationship-building and collaboration skills across interdisciplinary teams and community partners
  • Knowledge of healthcare, rehabilitation, community support, and social service systems
  • Excellent communication, documentation, and organizational skills
  • Commitment to person-centered, culturally responsive, and accessible service delivery
  • Degree in Social Work, Occupational Therapy, Physiotherapy, Nursing, Rehabilitation Sciences, Health Sciences, Disability Management, Healthcare Administration, or a related field
  • Minimum three years of experience in care coordination, hospital discharge planning, healthcare transitions, rehabilitation services, complex care, community health, or a related setting
  • Experience working within interdisciplinary healthcare or community-based teams supporting individuals with complex medical, functional, psychosocial, or accessibility needs
  • Knowledge of vision rehabilitation and the impact of vision loss is considered an asset
  • Registration in good standing with a relevant provincial regulatory body is considered an asset
  • Equivalent combinations of education and directly related experience will be considered
  • Valid driver's license and ability to travel as required
  • Current satisfactory Criminal Record Check and Vulnerable Sector Check

Benefits

  • Comprehensive benefits, including health, vision, dental, corporate discounts, and an employee and family assistance program
  • Flexible work arrangements
  • Generous paid time off
  • Work-life balance initiatives
  • Career development through training, mentorship, and advancement opportunities
  • Inclusive work culture with supportive teams
  • Employee recognition
  • Joy-in-work wellness program
  • Mental health supports
  • Accommodation to apply or participate in the selection process

Job type

Full Time

Experience level

Mid levelSenior

Salary

CA$38 - CA$42 per hour

Degree requirement

Bachelor's Degree

Location requirements

HybridNew WestminsterCanada

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