Transition Services Complex Coordinator

AHS is dedicated to Enhancing Care in the Community, helping people be healthy, well & independent in their homes and communities. Edmonton Zone Continuing Care provides services through five main program areas: Home Living, Supportive Living, Facility Living, Transition Services & Palliative Care. The Transition Coordinator - Complex (TC-Complex) is a clinical consult-based position. TCs assess patients’ needs in the context of the whole person including their life situation & determinants of health. Critical thinking & accurate interpretation of complex information from a variety of sources are essential to the clinical decision-making required for the determination of appropriate continuing care living options. The role of the TC is highly complex and includes comprehensive assessment, planning and coordination of care, as well as ongoing communication with other health-care providers across the continuum of care. Major responsibilities include completing a summary based on the Most Responsible TC’s comprehensive electronic needs assessments, determining urgency/ priority, developing & implementing appropriate service plans, coordinating service delivery across programs/settings, liaising with Continuing Care staff & other community resources, providing information & support to clients, families, & caregivers. The TC works within a multi-disciplinary team of health professionals & is responsible for appropriate referral to other programs/services, appropriate documentation, provides guidance in Complex case review conferences & team meetings, the complex review & recommendation process, & outcome evaluation & professional development activities. This position will be required to see complex clients in person within acute & community settings across the Edmonton Zone.

As a Registered Nurse (RN), you will provide a wide variety of nursing services to patients, families, communities and populations, while taking necessary steps to ensure their safety and well-being. In your role, you will utilize nursing processes, through critical thinking, problem solving and decision making, as well as teach, counsel and advocate on behalf of patients and their families. You will play a leadership role in supporting an integrated and holistic approach to patient care, health promotion and maintenance. You will provide safe, quality patient and family centered care while reflecting the shared vision and values of AHS. PLEASE NOTE: Provisional Permit Holders shall be paid $39.58 /hour - $54.16/hour. Upon being entered into the register of Registered Nurses, the rate of pay shall be adjusted to the rate of pay applicable to a Registered Nurse in accordance with AHS/UNA Article 25.02(b)(i) or (ii) as applicable.

Completion of an accredited nursing education program. Active or eligible for registration and practice permit with the College of Registered Nurses of Alberta (CRNA). Current Basic Cardiac Life Support - Health Care Provider (BCLS-HCP). If you have not practiced as a Registered Nurse within the last five (5) years, completion of the following free courses is required: CRNA Medication Management - Chapters 1 - 4 (https://connect.nurses.ab.ca/home/%2Flearning-and-development%2Flearning-modules%2F) and the NextGenU Health Assessment Resources Certification (https://courses.nextgenu.org/course/view.php?id=271#section-0)

Completion of an accredited nursing education program. Active or eligible for registration and practice permit with the College of Registered Nurses of Alberta (CRNA). Current Basic Cardiac Life Support - Health Care Provider (BCLSHCP). Minimum of five years Transition Coordinator experience in acute and community. A minimum of two years of experience within the community. Experience in home care, supportive living or facility living. Must lead and participate in multiprofessional rounds. Must work independently within acute and community settings and in a team environment. Effective time management and prioritization skills. Conflict resolution and strong communication skills. Ability to problem solve and demonstrate critical thinking skills. Ability to assess clients in person, irrespective of location and environment. Demonstrated ability to review, articulate questions to gather missing details, and provide feedback. on comprehensive assessments completed by other Transition Coordinators. Must provide feedback verbally 1:1, to multiprofessional team in rounds, and write clear recommendations in the EMR. Must cope with high levels of stress, fluctuating priorities, and time sensitive deadlines. Must tolerate long periods of sitting or standing as well as repetitive movements.

Knowledge of computer applications such as Microsoft Apps, Pathways, interRAI Tools, Connect Care and e-People is preferred and an asset.