Position Summary
The System Navigator provides client-centered support to individuals living with HIV and who may experience barriers to accessing health and social service systems. Through practical support, case management, education and coordination, the System Navigator assists individuals in navigating complex service systems while promoting dignity, autonomy, and equitable access to care.
Working collaboratively with healthcare providers, community organizations, and multidisciplinary partners, the System Navigator promotes timely access to HIV care and treatment, enhances continuity of care, and supports clients in achieving their self-identified goals while maintaining dignity, autonomy, confidentiality, and equitable access to services.
Core Responsibilities
1. Care Coordination and Clinical Navigation
- Build collaborative relationships with HIV clinics, hospitals, primary care providers, public health, pharmacies and community organizations.
- Coordinate transitions between hospital, primary care, pharmaceutical and community services.
- Make direct referrals for HIV clinical care and treatment and coordinate follow-up with HIV specialists, primary care providers and allied health professionals.
- Support clients in maintaining meaningful engagement in HIV care while identifying and responding early to barriers that may contribute to dis-engagement.
- Facilitate client enrolment with primary care providers.
- Facilitate communication among service providers while maintaining client confidentiality and informed consent.
- Maintain current knowledge of HIV treatment, prevention strategies and community resources.
- Assist clients in understanding available treatment options and community supports.
2. Client Support & System Navigation
- Conduct client-centered assessments and identify barriers to services.
- Provide time-limited case management for identified clients, using individualized Support Plans based on client’s self-identified goals.
- Review client goals, progress, and support need collaboratively at least every three months, or more frequently as needed, and update support plans to reflect changing priorities and circumstances.
- Assist clients in navigating social services, healthcare, housing, legal, income support, and immigration systems.
- Provide transportation and accompaniment to clients accessing health and social services as required, within agency parameters.
- Provide support with applications, forms, appointments, and service referrals to Ontario Works, ODSP, housing services, identification replacement, immigration documents, healthcare, mental health, harm-reduction service, addictions services and any other needs identified by client.
- Facilitate warm transfers to internal programs, community agencies and service providers.
- Provide crisis intervention and problem-solving support as required.
- Deliver information related to HIV, HCV, STBBIs, safer substance use, and overdose prevention.
- Provide supportive counselling and brief interventions related to HIV status, HIV care, mental health, and social determinants of health.
- Work collaboratively with internal and external service providers to ensure coordinated care.
- Foster collaborative relationships and strengthen referral pathways to improve coordination across the health and social service system.
- Work with agency leadership to advocate for equitable access to services and systemic improvements for people living with HIV.
- Promote inclusive principles and challenge stigma associated with HIV and harm reduction strategies.
- Support clients in making informed decisions regarding their health and well-being through culturally safe, trauma-informed, and person-centred approaches that honour each client's cultural values, beliefs, traditions, and lived experiences.
- Provide evidence-based education related to HIV, treatment adherence, prevention, sexual health and harm reduction.
- Participate in community committees, planning tables, working groups, and collaborative initiatives as assigned.
- Maintain awareness of emerging trends, service gaps, and community needs and communicate findings to the Supervisor and broader team to support program development and advocacy efforts.
Caseload Management and Client Assignment
The Support Program operates using a primary worker model to ensure continuity of care while maintaining service accessibility and team-based support.
- Each client receiving ongoing support will be assigned a Primary System Navigator who is responsible for coordinating services, maintaining documentation, monitoring progress toward client-identified goals, and acting as the primary point of contact for the client.
- The System Navigator team serve as backup support for all active clients and may provide support, advocacy, follow-up, transportation assistance, outreach, or case management coverage when the Primary System Navigator is unavailable.
- All System Navigators are expected to maintain familiarity with active client files and participate in regular case reviews to ensure continuity of care across the program.
- Referrals received will be directed to the Care Coordination Supervisor and assigned to System Navigators based on factors including:
- Current caseload capacity.
- Complexity of client needs.
- Existing service relationships.
- Geographic considerations; and
- Program priorities.
- Caseload assignments will be reviewed regularly through supervision, file audits, and team meetings to ensure equitable workload distribution and effective client support.
3. Documentation, Data Collection & Quality Assurance
Accurate documentation, data collection, and file management are essential functions of the System Navigator role.
- Maintain client records in accordance with agency policies, funder requirements, and professional standards.
- Complete assessments, support plans and referrals within established timelines. Case notes and follow-up documentation must be completed within 24–48 hours of client interaction.
- Utilize TREAT Database for client documentation, case management activities, progress notes, goal tracking, and statistical reporting.
- Create and maintain client files according to program standards and consent requirements.
- Upload and maintain all relevant supporting documentation to TREAT database including consents, identification, referrals, and other client-related records within 24-48 hours of receiving.
- Participate in Case Management file audits and case reviews.
- Assist in maintaining accurate active client lists and caseload records.
- Track service statistics and outcome measures mandated by agency and funder requirements.
- Ensure confidentiality and compliance with privacy legislation (PHIPA), agency policies, and documentation standards.
- Contribute to data collection initiatives that support program evaluation and continuous quality improvement.
- Complete agency assigned trainings.
4. Program Development, Team Collaboration & Administrative Responsibilities
The System Navigator contributes to the overall success of the Support Program and Positive Living Niagara.
- Attend and actively participate in agency meetings, department meetings, team meetings and weekly support huddles.
- Ensure all required administrative documentation for transportation remains up to date on all agency platforms. E.g. ODSP Mandatory Special Necessities (MSN) Benefit Application.
- Participate in professional development opportunities and required training.
- Maintain knowledge of community resources and update resource information as required.
- Contribute to shared resource calendars, maintain accurate information within the shift plan and other information systems.
- Utilize Teams, shared drives, and agency communication platforms to support collaboration and information sharing.
- Assist with service coverage across agency programs when operationally required.
- Participate in program planning, evaluation, and quality improvement initiatives.
- Support and promote Positive Living Niagara events, education sessions, and community engagement activities.
Organizational Responsibilities
All employees are expected to:
- Adhere to the Mission, Vision, Values, and Policies of Positive Living Niagara.
- Represent the agency in a professional, ethical, and respectful manner.
- Promote teamwork, collaboration, and effective communication.
- Foster inclusive, anti-oppressive, trauma-informed, and culturally responsive practices.
- Maintain professional boundaries and confidentiality.
- Demonstrate reliability, accountability, and commitment to scheduled work hours and assigned responsibilities.
- Support a workplace culture that values harm reduction, dignity, respect, equity, diversity, and inclusion.
- Assist with the coordination and delivery of other Positive Living Niagara programs when required.
- Any other duties as assigned by Supervisor and/or Director
Qualifications
Education
- A college or university degree in social or health services, with experience in the community social services sector
Experience
- Minimum of two years' experience delivering direct services and case management/system navigation support in community-based social services, such as settlement, mental health and addictions, health promotion, or related fields is required.
Required Skills & Competencies
- Knowledge and comfort working within the harm reduction framework.
- Knowledge of community resources, housing systems, income support programs, and service pathways in the Niagara Region.
- Excellent interpersonal, advocacy, engagement, and relationship-building skills.
- Ability to establish rapport with diverse populations.
- Strong organizational and time-management skills.
- Excellent verbal, written, documentation, and computer skills.
- Ability to work independently and collaboratively.
- Accurate record keeping and data collection abilities.
- Ability to manage competing priorities and respond effectively to crises.
- Commitment to anti-stigma, anti-oppressive, and client-centered practices.
- Second language skills are considered an asset.
- Knowledge of federal and provincial policies and legislation an asset e.g. affordable housing, immigration, income support is an asset.
- Lived experience with HIV/AIDS is highly valued.
Additional Requirements
- Valid unrestricted class G Ontario Driver's License.
- Access to a reliable vehicle for community collaboration and client support activities.
- Current vulnerable sector check required (within 6 months)
- Ability to work flexible hours, occasional evenings and weekends.
- Ability to work safely and effectively in office, community, and street-level environments.
To Apply:
Please submit your resume and cover letter to:
Vanessa Fyfe by August 07, 2026 at [email protected]
Video submissions in place of cover letter are accepted.
Note: No telephone inquiries, please.
Equity and Inclusion Statement:
Positive Living Niagara welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in all aspects of the selection process.
Positive Living Niagara is committed to employment equity and encourages applications from Black, Indigenous and racialized people, people of all gender identities and sexual orientations, and people with disabilities. Positive Living Niagara also recognizes the need for experience, knowledge and guidance from communities disproportionately affected by HIV and hepatitis C, including people living with HIV or with current or lived experience of hepatitis C or substance use.
Thank you to all who apply; however, only those selected for interviews will be contacted.
Pay: $48,935.00-$58,094.00 per year
Benefits:
- Casual dress
- Dental care
- Flexible schedule
- On-site parking
- Paid time off
- Vision care
Work Location: In person
