Care Coordinator – Nurse

Role Overview

• Complete intakes and nursing assessments to understand client needs, health history, social supports, caregiver needs, goals and appropriate program/resource pathways.
• Develop, document and update care coordination plans with clients and caregivers, including priorities, realistic goals, follow-up actions and clear next steps.
• Support clients, caregivers and families through empathetic education, coaching and motivational interviewing so they understand provider instructions, symptoms, care plans, treatments, records and self-management needs.
• Navigate healthcare, community, social, benefits, workplace, wellness, travel and virtual resources; support appointment preparation, referrals and follow-up; identify gaps; and advocate respectfully for access, continuity and client preferences.
• Coordinate and share relevant information with authorized providers, care team members, program partners and internal colleagues in a timely, privacy-compliant manner to support transitions, reduce duplication and improve continuity of care.
• Provide non-emergency guidance, check-ins and monitoring; recognize changes, symptom concerns, mental wellbeing or caregiver concerns; and escalate for clinical review, provider follow-up or emergency care as appropriate.
• Use Serefin digital platforms, documentation tools and communication pathways securely to consolidate health information, manage caseload priorities, maintain confidentiality and support high-quality care.
• Collaborate with colleagues and leaders to strengthen care coordination resources, referral/resource libraries, workflows, digital tools, platforms and communication pathways; participate in meetings, training and quality improvement.
• Work independently with sound judgement while remaining responsive, team-oriented and aligned with clinical standards, policies and operational needs.
• Support the organization's operational priorities and contribute to other business initiatives as required.

Requirements

• Registered Nurse (RN), Registered Practical Nurse (RPN), or Licensed Practical Nurse (LPN) currently registered and in good standing with their respective college.
• Minimum 3 years of nursing experience in acute care (e.g., Emergency, Medicine, ICU), community care, primary care, complex care, or a related setting.
• Experience in nursing with the elderly population and individuals with complex needs is desirable.
• Strong assessment, triage, documentation, teaching, and coaching skills.
• Ability to support clients, caregivers and families through complex, sensitive or emotional conversations with empathy, professionalism, cultural humility and clear boundaries.
• Demonstrated problem-solving, decision-making, and critical thinking skills while effectively managing multiple priorities.
• Works well both collaboratively and independently.
• Excellent interpersonal and communication skills, both oral and written.
• Proficiency in English is required. French fluency is strongly preferred; additional languages are an asset.
• Comfortable using technology, including electronic documentation platforms, Microsoft 365 applications, telephone systems, and other digital tools.
• Must have a private, secure workspace with a door that can be closed to maintain client privacy and confidentiality.
• Up-to-date Police Reference Check.
• The role requires the ability to work regularly on evenings, nights, weekends and statutory holidays.