Care Coordinator – Complex Vulnerable with a primary Refugee Health focus (1.0 FTE)

141 Weber Street South, Waterloo ON, N2J 2A9

Posting: #19-O-24

Closing: March 18, 2019

Schedule: 7 hours/day, prescheduled. May be required to provide relief at other LHIN locations/teams as needed. 

Union: ONA

Rate of Pay: $33.95 - $45.26 / hr

Reporting to: Manager, Client Services


  • To act as an organizational lead within the Waterloo- Wellington LHIN for all refugee health and complex vulnerable needs. Main areas of focus will involve supporting refugee and complex vulnerable populations in accessing community resources and obtaining meaningful primary attachment within the WWLHIN. 
  • While ensuring a health equity focus, this position will be responsible for supporting complex vulnerable and refugee patients by completing comprehensive assessments to inform coordinated care plans for patients across WWLHIN. 
  • Working closely with local Primary Health Care providers as well as other community partners, this position will be integral in ensuring refugees and complex vulnerable residents including indigenous residents are receiving the right care at the right time. 


The incumbent will be responsible for:

  • Engage in health system improvement by participating in research, quality improvement initiatives, systems projects and pilots that support the development and integration within the Ontario health care system  
  • Engaging the client by establishing a committed relationship; to work with the client in addressing his or her needs and goals;
  • Assessment of referred clients to obtain information in order to identify a client’s functional & cognitive status, strengths, values, abilities, preferences, resources, supports and need
  • Determination of eligibility for services or programs based on legislation, standards, regulations; policies and funding options
  • Develop individual patient centred coordinated care plans in collaboration with client/ Substitute Decision Maker and with other providers to address refugee health needs by utilizing information from the assessment, legislation, standards, regulations and policies
  • Implementation of the care plan, including monitoring and evaluation to ensure that the goals of the care plan are achieved 
  • Reassessment of clients’ needs and evaluation of the level of goal achievement related to the care plan;
  • Planning for discharge once the identified goals and outcomes have been achieved;
  • Support meaningful long term attachment through facilitating transitions from initial primary refugee health care providers to other primary care providers throughout the WWLHIN. 
  • Serve as primary contact, advocate, and system resource for refugee patients.
  • Support and develop patient’s independence in navigating the Ontario health care system through culturally and linguistically appropriate education
  • Connect patients to relevant community resources with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
  • Promote and build capacity for coordinated are plans for complex vulnerable patients across the WWLHIN.
  • Maintains confidentiality of client records;
  • Documents according to WWLHIN and professional college standards of documentation.
  • Participation in program development/research and professional development;
  • Working in a multi-disciplinary team with community partners that promotes positive working relationships;
  • Takes all reasonable steps to ensure a healthy and safe work environment and participates in continuous quality improvement. Working in partnership with Centre for Family Medicine, Reception House and Sanctuary Health Centre
  • Other duties as required


  • One – three years’ experience in a community health or related environment.
  • Membership in good standing, with the appropriate college, as a Registered Nurse, Occupational Therapist, Physiotherapist, Speech Language Pathologist or membership in good standing with the College of Social Work, with a degree at the Master’s level.
  • Certificate in Case Management is an asset.
  • Proficient in the operation of a personal computer in a networked environment using a variety of computer software and data entry skills, i.e. Excel, Data Base Software, as well as various other programs.
  • Knowledgeable in the use of technology in a community setting – e.g., lap top in the home, cell phone, remote networking, etc.
  • Demonstrated skill in setting and meeting deadlines;
  • Demonstrated effective use of time and tools to manage work efficiently.
  • Demonstrated experience in comprehensive assessment, use of different or combined approaches.
  • Preference will be given to applicants who have experience and expertise in mental health and pediatrics
  • Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
  • Comfortable with completing assessments and patient care using translators
  • Demonstrated skills in synthesizing information in order to plan and adjust services and to assist clients with informed decision-making.
  • We require analysis and critical thinking related to service authorization and management of budget for the caseload.
  • Knowledge of care coordination principles and practices;
  • Knowledge of LHIN policies & procedures, legislation & regulations;
  • Knowledge of health care related legislation and practices with respect to refugee health; including interim federal health funding 
  • Knowledge of community resources, services and the roles of health professionals/support workers;
  • Knowledge of prevention and health promotion.
  • This position will initially be based out Waterloo Office; however office location is subject to change based on the needs of the residents.           
  • Must have own transportation.
  • Willingness to participate in conferences, working groups, training and/or meetings within the Waterloo Wellington geographical area

Preference will be given to individuals with education and skills related to pediatric and mental health for vulnerable complex residents of our community.  RN or OT strongly preferred.

This position may be required to provide relief at other LHIN locations or teams as needed and may be part of the on call rotation as per the provisions of the ONA collective agreement.

WWLHIN strives to create a respectful, accessible and inclusive work environment.  Upon individual request, hiring processes will be modified to remove barriers to accommodate those with disabilities.  Should any applicant require accommodation through the application, interview or selection processes, please contact Human Resources at for assistance. 

If you are interested in this position, please submit a cover letter, along with a detailed resume, outlining how your skills, qualifications and experience meet the position requirements, quoting posting #19-O-24 before 4:30p.m. on March 182019 to Human Resources (e-mail We thank all applicants in advance; however, we will be communicating only with those selected for an interview.

*** PLEASE NOTE*** Cover letters and resumes need to be submitted as a single file, acceptable files are: doc, docx, and pdf. Please include your first name, last name and job title in the file name when applying, example JohnSmith_Recruiter.