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.

Duties

• Coordinate and implement patient-centred care plans with patients, families, caregivers, and the interprofessional team to support seamless transitions across the continuum of care and community services
• Coordinate complex referrals and facilitate equitable access to health, social, housing, and community services
• Assess referral appropriateness, identify barriers to care, and develop strategies to improve access to required supports and services
• Serve as a clinical and operational resource on referral pathways, eligibility requirements, community resources, and access processes
• Provide consultation, coaching, education, and guidance to clinical teams, learners, community partners, and referring providers on referral management and care coordination
• Facilitate communication and collaboration among interdisciplinary teams and community organizations to support integrated care delivery
• Support staff onboarding and ongoing education related to referral processes, Social Medicine services, and community resources
• Identify and resolve referral, service access, and care coordination issues through collaboration and problem-solving
• Assist with workload prioritization, referral coordination, and service allocation across program areas
• Promote patient-centred, trauma-informed, anti-oppressive, and equity-focused approaches to care
• Develop and monitor referral performance indicators, including service utilization, access targets, turnaround times, and patient outcomes
• Collect, analyze, and report operational and referral data to support decision-making, program evaluation, planning, and quality improvement
• Conduct audits and evaluations to identify trends, gaps, risks, and opportunities for improvement
• Develop and maintain dashboards, reports, tracking tools, and performance metrics to support program accountability
• Recommend and implement process improvements to enhance patient access, operational effectiveness, and care coordination
• Monitor referral workflows and operational performance, escalating issues that may impact patient safety, service quality, or equitable access to care
• Participate in quality improvement initiatives, program evaluations, and strategic planning activities
• Build and maintain collaborative relationships with healthcare providers, community agencies, housing organizations, social service partners, and other stakeholders
• Act as a liaison between Social Medicine services and external partners to support coordinated and integrated models of care
• Contribute to service planning, resource allocation, and referral pathway development to address emerging patient and system needs
• Support initiatives that improve access for marginalized, underserved, and structurally vulnerable populations
• Represent the Social Medicine Program in committees, working groups, meetings, and community initiatives
• Promote awareness and utilization of Social Medicine services among internal and external stakeholders
• Provide leadership, consultation, and subject matter expertise in system navigation, community resources, social determinants of health, and equitable access to care
• Contribute to program development, policy development, and organizational initiatives that advance Social Medicine and Population Health priorities
• Foster a culture of collaboration, innovation, continuous learning, accountability, and excellence
• Maintain current knowledge of emerging practices, legislation, and health system priorities relevant to the role
• Participate in corporate committees, special projects, and organizational initiatives that support program and organizational effectiveness

Qualifications

• 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