Job Description

Union: Non-Union
Number of vacancies: 1
New or Replacement: New
Site: Various
Department: Social Medicine & Population Health
Reports to: Senior Manager
Salary Range: $73,000 - $91,347
Hours: 37.5 hours per week
Shifts: Days
Status: Permanent Full-Time
Closing Date: September 9, 2026

Position Summary

The Social Medicine Referrals Coordinator provides clinical-operational leadership in coordinating equitable access to Social Medicine services for patients with complex medical, psychosocial, and health equity needs. As an integral member of the interprofessional team, the Referrals Coordinator is responsible for implementing, coordinating, monitoring, and evaluating referral pathways and care transitions across the health and social care continuum. The role functions as a key liaison between patients, families, healthcare providers, community organizations, and system partners to facilitate timely, integrated, and patient-centred care. The Referrals coordinator exercises independent judgment in assessing referral appropriateness, addressing barriers to access, resolving complex service navigation issues, and facilitating seamless transitions between hospital, community, and social service systems. The Social Medicine Referrals Coordinator provides subject matter expertise, operational leadership, and consultation regarding referral management processes, access optimization, health equity initiatives, community partnerships, quality improvement, and performance measurement. The role contributes to program planning, service development, and system improvement initiatives aimed at advancing access to care and improving outcomes for marginalized and structurally vulnerable populations.

Responsibilities

KEY RESPONSIBILITIES

• Implements and coordinates patient-centered care plan with patients and the multi-disciplinary team for the purpose of facilitating the patient's movement through the continuum of care and within the community.
• Implements and coordinates patient-centred care plans with patients, families, caregivers, and the interprofessional team to facilitate timely movement through the continuum of care and within community-based services.
• Coordinates complex referrals and access to health, social, housing, and community services, ensuring appropriate and equitable service utilization.
• Assesses referral appropriateness, identifies barriers to care, and develops strategies to facilitate access to required services and supports.
• Acts as a clinical and operational resource regarding referral pathways, eligibility criteria, community resources, and access processes.
• Provides coaching, guidance, consultation, and education to clinical teams, learners, community partners, and referring providers related to referral management and care coordination.
• Facilitates communication among interdisciplinary teams and community organizations to support effective transitions of care.
• Participates in staff onboarding, orientation, and ongoing education related to referral processes, social medicine services, and community resources.
• Identifies and resolves referral-related issues, service access concerns, and care coordination challenges through collaboration and problem-solving.
• Assists with workload prioritization, coordination of referral activities, and service allocation across program streams as required.
• Serves as a resource and role model by promoting patient-centred, trauma-informed, anti-oppressive, and equity-focused approaches to care.
• Develops, implements, and monitors referral performance indicators, including referral volumes, service utilization, turnaround times, access targets, and patient outcomes.
• Collects, analyzes, interprets, and reports referral and operational data to support decision-making, program evaluation, operational planning, and quality improvement initiatives.
• Conducts audits of referral processes, access outcomes, and service utilization to identify trends, gaps, risks, and opportunities for improvement.
• Develops and maintains dashboards, tracking tools, reports, and performance metrics to support program accountability.
• Recommends, implements, and evaluates process improvements that enhance patient access, operational efficiency, and care coordination.
• Monitors referral workflows and operational performance, identifying barriers and escalating issues that may affect patient safety, service quality, or equitable access to care.
• Participates in quality improvement initiatives, program evaluations, and organizational projects designed to improve service delivery and patient outcomes.
• Participates in operational and strategic planning activities supporting the goals and objectives of the Social Medicine Program.
• Develops, strengthens, and maintains collaborative relationships with community agencies, primary care providers, housing organizations, social service agencies, and other system partners.
• Acts as a liaison between Social Medicine services and external referral partners to facilitate integrated care delivery and service coordination.
• Contributes to service planning, forecasting, resource allocation, and referral pathway development to address emerging patient and system needs.
• Supports the design, implementation, and optimization of referral pathways that improve access for marginalized, underserved, and structurally vulnerable populations.
• Represents the Social Medicine Program at internal and external meetings, committees, working groups, and community initiatives, as appropriate.
• Promotes awareness, understanding, and utilization of Social Medicine services among internal and external stakeholders.
• Participates in partnership-building activities and community initiatives that address social determinants of health and support integrated models of care.
• Contributes expertise to organizational initiatives focused on health equity, population health, patient access, and system transformation.
• Provides functional leadership, guidance, and consultation to staff, learners, and community partners regarding referral management processes and best practices.
• Acts as a subject matter expert in system navigation, community resources, social determinants of health, and equitable access to care.
• Participates in program development, policy development, and operational initiatives to advance Social Medicine and Population Health priorities.
• Supports a culture of continuous learning, collaboration, innovation, accountability, and excellence.
• Participates in professional development activities and maintains current knowledge of emerging practices, legislation, and health system priorities relevant to the role.
• Performs cross-functional and organizational responsibilities that support the goals, strategic priorities, and mission of the Social Medicine and Population Health Program and University Health Network.
• Participates in corporate committees, special projects, organizational initiatives, and activities that contribute to program and organizational effectiveness.
• Works in compliance of the Occupational Health & Safety Act and its regulations, reporting hazards, deficiencies and contravention's of the Act, in a timely manner.
• Works in compliance with the Occupational Health & Safety Act and its regulations, reporting hazards, deficiencies, incidents, and contraventions in a timely manner.
• Promotes a safe work environment and contributes to workplace practices that support employee, patient, and community safety.

Qualifications

• At minimum, a bachelors degree in health sciences, social services, community development, public health, social work, or related field or recognized equivalent required.
• Experience working with patients experiencing marginalization, homelessness, substance use and mental health challenges.
• Experience coordinating referrals or patient intake processes in health, community or social service settings.
• Experience with the provision of trauma-informed care, harm reduction principles, and anti-racist, anti-discriminatory, anti-oppressive practices
• Strong knowledge of, and familiarity with, community resources that address the social determinants of health
• Strong understanding of acute care and community health settings and ability to navigate health systems an asset
• Well-developed decision-making, problem-solving, and judgement skills
• Experience developing community partnerships and collaborative service pathways.
• Excellent interpersonal, oral, and written communication skills
• Experience in program development and implementation
• Experience analyzing operational data and preparing reports.
• Effective time management, prioritization and organizational skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment
• Proven ability to work as a team member and independently
• Ability to have and use diplomacy and tact at all times
• Knowledge of Epic an asset

Additional Information