I. Position Summary

The Clinical Service Coordinator is responsible for supporting individuals experiencing vision loss as they transition from hospital to home and community-based rehabilitation services. Serving as the primary point of contact from referral through service delivery, this role provides case management, care coordination, system navigation, and client advocacy to ensure individuals receive timely access to rehabilitation, healthcare, and community supports.

Working closely with hospitals, healthcare providers, clients, families, and VLRC's interdisciplinary team, the Clinical Service Coordinator helps remove barriers to care, supports successful transitions, and promotes client independence, safety, and quality of life. Success in this role requires strong case management, discharge and transition planning, care coordination, sound clinical judgment, exceptional relationship-building skills, and the ability to navigate complex healthcare and community service systems. Knowledge of vision rehabilitation is an asset; however, comprehensive training related to vision loss, rehabilitation pathways, and VLRC services will be provided.

II. Key Responsibilities

Client Assessment, Case Management & Service Planning

·         Serve as the primary point of contact for clients referred to the Hospital-to-Home Program, leading intake, needs assessment, service planning, and coordination of supports throughout the transition from hospital to community-based rehabilitation.

·         Conduct intake, needs and risk assessments to identify client goals, rehabilitation priorities, support requirements, and barriers to independence and community living.

·         Develop and monitor individualized service plans that connect clients with appropriate rehabilitation, healthcare, and community resources.

·         Apply sound judgment to prioritize referrals, identify safety or psychosocial concerns, and facilitate timely intervention or referral when required.

·         Establish baseline outcomes and monitor progress to support successful transitions and achievement of client goals.

Care Coordination and Healthcare Transitions

·         Coordinate admission to VLRC services and facilitate timely commencement of appropriate rehabilitation supports.

·         Collaborate with hospitals, healthcare providers, community organizations, and referral partners to develop integrated transition plans and support positive client outcomes.

·         Assess discharge readiness, support systems, living circumstances, and service requirements to ensure continuity of care across providers and settings.

·         Serve as the central liaison among clients, families, healthcare professionals, and rehabilitation teams, facilitating communication, problem-solving, and shared care planning to rehabilitation, healthcare, and community supports.

·         Participate in case conferences, discharge-planning discussions, and interdisciplinary care meetings.

·         Support clients and families in navigating complex healthcare and community systems while advocating for access to appropriate services and resources.

Documentation, Outcomes and Follow-Up

·         Ensure accurate and timely documentation of client interactions, assessments, service plans, outcomes, and follow-up activities in compliance with organizational and professional standards.

·         Monitor client progress, service delivery metrics, and rehabilitation outcomes to support informed decision-making and program effectiveness.

·         Facilitate successful transitions of care by coordinating follow-up activities, resolving outstanding service needs, and supporting planned case closures

Quality, Safety and Program Development

·         Identify and escalate clinical, psychosocial, accessibility, and service-related risks in accordance with organizational standards.

·         Contribute to program evaluation, quality improvement, and outcome measurement initiatives that support evidence-informed practice and continuous service enhancement.

·         Analyze emerging trends, service gaps, and system barriers to inform recommendations that improve client access, care coordination, and rehabilitation outcomes.

·         Foster collaborative partnerships through education, consultation, and outreach that increase awareness of vision rehabilitation services and strengthen integrated care pathways.

·         Support the ongoing development and refinement of hospital-to-home programs, referral pathways, and service delivery models.

·         Other duties as required.

Requirements

III. What You’ll Bring to the Role

·         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, with the ability to identify priorities, risks, and opportunities for intervention.

·         Proven ability to manage multiple clients, competing priorities, and timelines in a fast-paced healthcare or community setting.

·         Exceptional relationship-building and collaboration skills, with the ability to work effectively across interdisciplinary teams and community partners.

·         Knowledge of healthcare, rehabilitation, community support, and social service systems, with the ability to navigate services and advocate for client needs.

·         Excellent communication, documentation, and organizational skills.

·         A commitment to person-centered, culturally responsive, and accessible service delivery.

Qualifications

·         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 to support individuals with complex medical, functional, psychosocial, or accessibility needs.

·         Knowledge of vision rehabilitation and the impact of vision loss is considered an asset.

Additional Requirements

·         Registration in good standing with a relevant provincial regulatory body (e.g., Social Work, Occupational Therapy, Physiotherapy, Nursing) 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

At VLRC, your work has real impact. Join a team that empowers Canadians with vision loss to live independently, and where your growth, well-being, and contributions matter. We offer:

·         Comprehensive benefits, including health, vision, dental, corporate discounts, and an employee and family assistance program

• Flexible work arrangements, generous paid time off, and work-life balance initiatives
• Career development through training, mentorship, and advancement opportunities

·         Inclusive work culture with supportive teams, employee recognition, a joy-in-work wellness program, and mental health supports

Join us to grow your career and make a difference every day.