Transitions Care Lead

Competitive Total Rewards So much more than a paycheque! Enjoy comprehensive benefits, pension, flexible pay options, car-loan support, housing solutions and exclusive staff perks.

Flexibility & Belonging Thrive with hybrid work, flexible scheduling and a supportive, inclusive culture that puts people first.

Purpose & Impact Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada.

Growth That Meets Your Ambition Access tuition support, training and meaningful career pathways across a growing, future-focused organization.

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.

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