The Transition Coordinator is responsible for scheduling Personal Support Workers and managing client intake, service plans, and transitional care coordination. They also analyze patient eligibility data and facilitate referrals to community resources to support seniors and vulnerable individuals.
Requirements summary
Candidates must have a bachelor's degree in a health-related field and at least 2-3 years of experience in geriatrics, mental health, or acute care. Proficiency in client information systems and strong assessment skills are required for this role.
Competition # 2026-212-CCTransition Coordinator (2026-212-CC)Employment Type
Permanent
Full-Time,
Bargaining
Unit (1
Vacancy)Work
Hours:35 hours/week (M-F 9am-5pm)Work
Setting:Exclusively onsiteSalary:External
Rate: $54,097.76
Internal
Rate: $55,201.79Application
Deadline:May 08, 2026 by 11:59 pm
Program Overview – Community Care, Home & Cluster Care Community Care for Seniors provides a holistic approach to care at home for seniors and caregivers who are vulnerable, at risk and/or marginalized. The unit provides a wide range of programs such as Assisted Living Services, Social Work, Meals-on-Wheels, Adult Day programs and transportation, which enable seniors to be as independent as possible in their homes with a variety of socio-recreational/wellness programs which enhance quality of life and promote the health of older adults
What You Will Do
Schedule a team of Personal Support Workers on a day-to-day basis for a program in operation 7 days a week, 24 hours per day and 365 days per year.
Prepare scheduling assignments for a team of PSWs according to availability, training, and seniority.
Ensure that the scheduling needs meet the standards and guidelines as established by the Manager and possible funding agencies.
Ensure adherence to established policies and procedures as it pertains to scheduling issues.
Refer breach of policies and procedures of Personal Support Workers to the Supervisor for follow-up.
Communicate regularly with and provide support to other program workers regarding intake for new clients (internal and external), scheduling, billing and all other aspects of client and PSW scheduling.
Coordinate with the Finance Unit regarding billing, accounts receivable.
Ensure that client documents are updated, signed-off, and secured in a confidential manner.
Maintain accurate records and complete documentation in a timely manner; collect statistical data required for the accountability of the program using relevant databases (i.e. Alayacare, QHR).
Provide information to clients with respect to service needs, scheduling, and emergencies.
Provide backup for team members, particularly other schedulers for periods of absence.
Participate in supervision sessions and annual performance appraisals.
Provide service that is responsive, culturally, and linguistically sensitive to the individual and caregivers needs.
Provide transitional care coordination for clients.
Conduct screenings (such as InterRAI Community Health Assessments or other preliminary Screeners) for program and client onboarding, inclusive of program orientation.
Collaborate with clients and caregivers to prepare service plans agreements.
Identify the need for and participate in or facilitate case conference and clinical meetings.
Link clients and/or their family or caregivers to various community resources and facilitate appropriate referrals internally and to other community support services as required.
Keep current about the range of services available across departments and at other agencies.
Extract data and analyze patient eligibility for programs & services from Michael Garron Hospital discharge and admission lists through PowerChart.
What You Bring to the Team
2+ years related experience including significant direct experience in working older adults and seniors with mental health (including dementia) and/or substance use issues, chronic health issues, cognitive impairment, and responsive behaviours.
3+ years of experience in hospital based acute care, mental health, geriatrics and/or social work.
Bachelor’s degree in health-related field (e.g. Social Work, Nursing, Gerontology), or equivalent.
Registered Social Worker (RSW) in good standing with the OCSWSSW an asset.
What Will Set You Apart
Applied computer skills (MS word, excel, Internet) and ability to use client information systems.
Data analysis is an asset.
Ability to communicate in a second language (Greek, Spanish, Bengali, Urdu, Tamil, Persian, Tagalog, Arabic, Mandarin, or Cantonese) is a strong asset. Strong assessment, clinical, and intervention skills.
Well organized, adaptive to changes, and able to work independently.
Patient, flexible and adaptive to changes.
Ability to be self-directed, flexible and exercise good judgment with minimal supervision.
Ability to work effectively in a multi-disciplinary team or as a team member in collaboration with other community professionals.
Good understanding of seniors’ health and wellness issues and knowledge of community resources for older adults.
Capable of fulfilling the physical and mental demands of the job as per the Postion Demands Analysis
WoodGreen is an equal opportunity employer. We are committed to providing an inclusive and barrier-free selection process and work environment. If contacted in relation to an employment opportunity, please advise our People & Culture representatives at careers@woodgreen.org [http://careers@woodgreen.org] of the accommodation measures required. Information received relating to accommodation will be addressed confidentially.
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