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Added 3 mins ago
VA
Veterinary Technician (RVT) - General Practice, Alta Vista Specialty & Emergency Veterinary Centre
VCA Animal Hospitals
Ottawa, ON
- Full-time
…places to work and programs for young people starting their careers. Most recently, we received 2026 Great Place to Work® Certification™…
Added 34 mins ago
LC
Grocery Clerk Part Time Night Greenlight Requisition
Loblaw Companies Limited
Ottawa, ON
- Part-time
…through our Blue Culture. We offer our employees progressive careers, comprehensive training, flexibility, and other competitive benefits – these are some of the many reasons why we are one…
Added 34 mins ago
LC
Produce Clerk Part Time Day Greenlight Requisition
Loblaw Companies Limited
Edmonton, AB
- Part-time
…through our Blue Culture. We offer our employees progressive careers, comprehensive training, flexibility, and other competitive benefits – these are some of the many reasons why we are one…
Added 34 mins ago
NS
Manager, Financial Reporting
Nova Scotia Power
Halifax, NS
- Full-time
Added 34 mins ago
NS
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NS
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AC
Early Careers: Broker, Risk Solutions - Halifax
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Added 34 mins ago
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Intern, Project Delivery and Hire & Buy Local
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Added 34 mins ago
VC
Veterinarian, Lexington Rd Animal Hospital
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…places to work and programs for young people starting their careers. Most recently, we received 2026 Great Place to Work® Certification™…
Added 34 mins ago
VC
Emergency Veterinarian, London Regional Veterinary Emergency and Referral Hospital
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- Volunteer
…places to work and programs for young people starting their careers. Most recently, we received 2026 Great Place to Work® Certification™…
Added 34 mins ago
SH
Back of House - Prep Cook
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Added 48 mins ago
LH
Registered Clinician - PT / OT
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- Full-time
At Lifemark, we're helping clinicians build meaningful, rewarding careers across Western Canada.
Added 48 mins ago
OL
Education Coordinator
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- Full-time
Added 48 mins ago
A
Senior Interaction Designer [AQ-24377]
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…perspectives are valued, and everyone can contribute, grow their careers, and…
Added 48 mins ago
VA
Registered Veterinary Technician - Emergency, Toronto Veterinary Emergency Hospital
VCA Animal Hospitals
Toronto, ON · Scarborough, ON
- Full-time
…places to work and programs for young people starting their…
Added 48 mins ago
VA
Veterinary Assistant, General Practice, Alta Vista Specialty & Emergency Veterinary Centre
VCA Animal Hospitals
Ottawa, ON
- Full-time
…places to work and programs for young people starting their careers. Most recently, we received 2026 Great Place to Work® Certification™…
Added 1 hour ago
SD
Pharmacy Intern, Hourly Full Time Flexible Shifts
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- Full-time
We can offer progressive careers, comprehensive training, flexibility and a great benefits package! Come share our vision and passion in delivering a superior customer experience. Be a part…
Added 1 hour ago
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SAP Operations Clerk Part Time Day Greenlight Requisition
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…difference in the community. We offer our colleagues progressive careers, comprehensive training, flexibility and a benefits…
Added 1 hour ago
GT
Senior Associate, Audit – Relocate to Australia
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In Australia we're proud to support the careers of more than 1,500 remarkable people. Backed by six Australian offices and a global network spanning more than 150 markets, we offer the…
Added 1 hour ago
NS
Utilityworker I
Nova Scotia Power
Sydney Indian Reserve No. 28A, NS · Sydney, NS
- Full-time
Added 1 hour ago
NS
Power Plant Technician II (Instrumentation Technician &/or Industrial Electrician)
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Added 1 hour ago
SH
Back of House - Supervisor, Culinary
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Added 1 hour ago
NS
Distribution Asset Strategy Engineer
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Added 1 hour ago
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SE Health

Transitions Care Lead

ON, Canada
Halton, ON, Canada

The hiring pay range is $69 000.00 - $87 000.00 per annum based on experience. · Full-time

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Job details

Pay: The hiring pay range is $69 000.00 - $87 000.00 per annum based on experience.
Job type: Full-time
Apply by: Nov 27, 2026
Experience: 3+ years of recent experience in community health or a related field.
Posting language: English
Posted: Oct 28, 2026

Original job description

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.

Hybrid position

Why join our team?

Competitive Total Rewards. So much more than a paycheque! Enjoy comprehensive benefits, pension, on-demand pay, car loan support, supportive housing and exclusive staff perks.
Growth That Meets Your Ambition Build your skills with education bursaries, tuition support, ongoing training and mentorship. Our leadership team is available 24/7 to help you practice to full scope and deliver excellent care. With diverse roles and locations across Canada, you’ll have opportunities to explore new career paths or move into support and leadership positions.
Innovative.   At SE, we are always looking for new, innovative ways to improve. You’ll be encouraged and supported to identify and make improvements to the way we do our work. As a social enterprise, we support research into Senior’s Health and Aging.
Purpose & Impact Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada.
Manage your life.  At SE, you’ll be supported with the time you need to meet the needs of your clients and meet your own needs, develop yourself and your career, and be part of a team.
Support to be your best. At SE you are afforded the time you need to help patients, to build rapport, to accomplish patient care and recovery goals, and to understand the home and life environments that impact recovery in a way you can’t in most other settings. At SE, you meet your patients where they are, and together you take them to new heights!

Position Summary

As the Transitions Care Lead You will provide exemplary leadership and care flow management between the hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives. This exciting position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client’s home environment. Additionally this position will help to ensure performance targets are met and be involved in quality improvement initiatives as it relates to optimizing patient flow and management processes within the Acute Transition programs.

Responsiblities

Act as the primary point of contact for the hospital navigator/coordinator
Receive, monitor and update the client tracking/notification/flow tools
Receive, review, and accept referrals for in-home transition services
Coordinate/Liaise with hospital navigator/coordinator and SE @home Team as required.
Participate in hospital discharge care conference for complex clients as required
Prepare an initial care plan (e.g. for 48-72 hours post transition) and place an initial equipment and supplies order as required
Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE @Home Team
Attend program huddles with hospital (as per contract requirements)
Monitor and communicate significant deviations from the care plan to the hospital as required.
Communicate to the hospital any risk-related events
Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital(required in contract)Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
Facilitate risk management as per established policies and procedures
Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings
Participate in program evaluation and process improvement
On-call as required for programs support
Other duties to ensure program is running smoothly

Requirements

Membership, in good standing, with the applicable regulatory body:
College of Nurses of Ontario.
College of Physiotherapists of Ontario.
College of Occupational Therapists of Ontario.
Ontario College of Social Workers and Social Service Workers.
3+ years of recent experience in community health or a related field.
Knowledge of the health care delivery system including hospital discharge planning, community care and support services
Excellent skills in case management and coordinating care within interdisciplinary teams
Excellent assessment and decision-making skills
Passion for excellent customer service and customer experience
Demonstrates strong critical thinking, problem-solving and self-directed skills.
Excellent interpersonal communication, and presentation skills with a diverse group or stakeholders (hospital partners, front line staff, management team)
Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community).
Advanced s k ills in M ic r o s o f t Off i ce (Word, Excel, PPT, Visio) and comfort with learning/working with new and emerging technologies (e.g. remote patient monitoring/virtual care technologies, EHR systems, reporting systems)
A valid driver’s license and access to a reliable vehicle.

About SE Health

SE Health is a not-for-profit social enterprise advancing health with heart. With 115+ years of impact, we bring hope, happiness and exceptional care to people and communities across Canada. We lead with empathy, dignity and purpose while building a future where everyone can realize their full health and well-being potential. We’re also an inclusive, supportive workplace offering competitive compensation, strong benefits and real opportunities to grow. We’re All In Together.

Accessibility: If you require accommodations due to illness or disability, please contact Talent Acquisition at careers@sehc.com .

AI And Compensation Details

We use AI to take notes during our interview. All applications and interviews are reviewed by our Talent Acquisition team. This role is a (new addition or replacement position). The hiring pay range is $69 000.00 - $87 000.00 per annum based on experience.

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More about this job

Responsibilities

Lead care flow and coordinate transitions between hospital partners and community care teams, including reviewing referrals, preparing initial care plans, and ensuring required documentation and equipment are arranged. Monitor program metrics and risks, communicate with hospital partners, and contribute to program evaluation and process improvement.

Requirements

Requires at least three years of recent experience in community health or a related field, plus good standing with an applicable Ontario regulatory body for nursing, physiotherapy, occupational therapy, or social work. Candidates need strong care coordination, assessment, communication, and decision-making skills, proficiency with Microsoft Office and emerging care technologies, and a valid driver’s license with access to a reliable vehicle.

Skills

Care Coordination
Case Management
Hospital Discharge Planning
Client Assessment
Clinical Decision-Making
Critical Thinking
Problem-Solving
Risk Management
Interdisciplinary Collaboration
Patient Flow Management
Quality Improvement
Stakeholder Communication
Time Management
Microsoft Office
Electronic Health Records
Virtual Care Technologies

Benefits

Comprehensive Benefits
Pension
On-Demand Pay
Car Loan Support
Supportive Housing
Staff Perks
Education Bursaries
Tuition Support
Ongoing Training
Mentorship

Visa sponsorship

Not detected in the job text

Keywords

Acute Care Transitions
Community Health
Hospital Discharge Planning
Community Care
Care Coordination
Case Management
Interdisciplinary Teams
Client Tracking
Referral Management
Initial Care Plans
Patient Flow
Care Conferences
Risk Management
Program Metrics
Client Experience
Quality Improvement
Program Evaluation
Remote Patient Monitoring
Virtual Care
Electronic Health Records
Microsoft Word
Microsoft Excel
Microsoft PowerPoint
Microsoft Visio
College of Nurses of Ontario
College of Physiotherapists of Ontario
College of Occupational Therapists of Ontario
Ontario College of Social Workers and Social Service Workers

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