Job DescriptionThe Remote Care Management (RCM) program is a partnership between Halton Healthcare, Connected Care Halton Ontario Health Team, and Ontario Health at Home (OHaH). Patients on this program interact regularly with our virtual health technology solutions. Patients then have their health checks and vital signs reviewed by the RCM Coordinator remotely. Patients can connect easily with a member of the RCM team if they have questions and there is a thoughtful escalation process in place should concerns arise both during and after regular program hours. This service is intended to help support self-management in the home, promote a shorter hospital length of stay and ideally reduce emergency department visits and/or readmissions. This position supports enrolled patients to navigate health systems by gathering information, liaising clients and families, and facilitating communication among members of the patient's circle of care in the hospital and in the community.
The RCM Coordinator will provide patient-centered system navigation, supporting the identification and on-boarding of patients eligible for the program. The RCM Coordinator works collaboratively with an inter-professional team, both internal and external to Halton Healthcare, including physicians, OHaH, Family Health Teams, Community Physicians, Halton Community Paramedicine, and specialty clinics to ensure patients are provided access to the support and benefits of RCM. RCM cares for patients with a variety of health, psychosocial, and surgical diagnoses.
The RCM Coordinator plays a key role in building and launching new RCM pathways that will aim to serve new populations and their respective diagnoses. This role will also have key responsibilities in compiling and validating RCM data from various sources.
Patient Identification and Care Planning (25%)- Work with hospital care teams to identify and discuss patients that meet criteria for the Remote Care Management program
- Attending inpatient hospital rounds, across multiple sites
- Review patient charts and consult with various members of the interdisciplinary team to assess medical and social needs
- Communication of the benefits of the RCM program to physicians, care coordinators, discharge planners, and other members of the multidisciplinary care team
- Meet with the care team to discuss current status, RCM eligibility, and barriers to discharge for eligible patients
- Meet with patients and their families at bedside as appropriate to discuss RCM program benefits and enrollment
- Assist in the completion and processing of RCM referrals
- Facilitate patients onboarding with the appropriate technological solution
- Using multiple remote monitoring technology platforms, provide appropriate clinical monitoring to enrolled patients and escalate patient needs to the appropriate clinical resource as per program standards
- Travel to patient homes as operational needs require to deliver items or troubleshoot technology/equipment challenges
Case finding and expansion of program to the community (25%)- Teaching, promoting and sharing of RCM information to Primary Care Providers, other community partners, and internal hospital teams - through virtual and in person formats
- Communication of the benefits of the RCM program to physicians, care coordinators, Family Health Teams and outpatient clinics.
- Support the coordination of care and development for individualized care plans for patients with linkages across hospital, community and primary care
- Participating in relevant in person hospital based and community based events
Program Coordination (25%)- Track and document referrals from care providers (hospital and community) for the RCM program.
- Enter data related to patients on-boarded on the RCM program and those patients who have declined, etc.
- Report any challenges, barriers and successes to key RCM partners
- Prepare and validate program results data
Program Development & Growth (25%)- Actively support all readiness and operational activities as new RCM pathways are approved, built and launched
- Co-chair and/or participate in various working group meetings that supports pathway development and quality improvements
- Facilitate and foster key partner relationships internally and externally
- Travel to and attend relevant community events including display/equipment set up and tear down
- Prepare internal, external and patient facing materials used to support new pathway launches
Qualifications- An undergraduate degree or diploma/certificate in a relevant health discipline field is required; Masters prepared is preferred
- Current membership in good standing with a regulatory health professional body in Ontario.
- Minimum 5 years of recent work experience in a hospital setting with specific experiences in acute care, surgery and post acute care
- Experience in acute care, primary care and/or community care settings
- Minimum 2-5 years' experience working within an inter-professional team environment, as well as independently and autonomously
- Minimum 2-5 years' experience working with older patients with complex needs
- Evidence of program and resource development skills, including knowledge of evaluation methodologies
- Experience in care coordination, case management, or resource management is highly valued
Knowledge & Competencies- Experience in performing case management functions is required
- Experience in program growth initiatives is an asset
- Strong understanding of collaborative practices, building partnerships both internally and externally
- Comprehensive knowledge of community resources and health delivery systems across acute and community settings
- Demonstrated ability to respond to patients and teams with flexibility, adaptability, and commitment to patient-centred and holistic care
Skills & Attributes- Excellent interpersonal, communication, organizational, clinical judgment and decision making skills required
- Consistently demonstrated strong leadership skills, including problem solving, critical thinking, conflict resolution, negotiation skills, and the ability to facilitate change and growth among teams
- Demonstrated ability to work independently and collaboratively with an interdisciplinary team, family members, support networks, and a variety of formal and informal service providers
- Strong leadership skills, including problem solving, critical thinking, conflict resolution, and negotiation abilities
- Demonstrated presentation skills for staff and patient education
- Comfortable working in an evolving program with changing responsibilities over time
- Excellent time management and stress management skills required
Technical Skills- Proficiency with Microsoft Office 365 applications required including Excel & Sharepoint for data collection and monitoring
- Experience with remote care monitoring digital solutions (SeamlessMD and TELUS preferred)
- Proficiency in electronic medical record systems; experience with Meditech preferred
- Ability to work in multiple digital solutions concurrently
- Fluency in English (verbal and written)
- Valid driver's license and ability to travel to locations through Halton Region and surrounding areas as operational needs require
Additional InformationHours: Monday to Friday, 7.5 hour shifts (Hours are subject to change based on operational needs)
Salary: $40.911 to $57.695 per hour
Date Posted: July 30, 2026
Internal Application deadline: August 6, 2026
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