OHT Primary Care Integration & Intake Navigator (RN)
Full-Time Contract until March 31, 2027 | Hybrid
Location: Newmarket, ON
35 hours per week | Monday–Friday (9:00am–5:00pm, 10:00am–6:00pm, or 11:00am–7:00pm) Hours are flexible and may vary depending on demand, particularly to support resident/patient outreach when people are more reachable outside standard daytime hours.
About the Role:
CHATS is seeking an experienced and highly collaborative Registered Nurse (RN) to serve in a Primary Care Integration & Intake Navigator role supporting primary care access, attachment, and coordinated navigation services across North York and South Simcoe region.
Position Summary
The OHT Primary Care Integration & Intake Navigator will function as the human integration layer across primary care, hospitals, Ontario Health partners, and community organizations. The role is focused on proactive outreach, relationship-based coordination, system navigation, and closed-loop referral management to support unattached and high-needs residents in accessing primary care services.
Working closely with primary care networks, hospitals, Ontario Health / HCC Care Connectors, and community agencies, the Navigator will help ensure referrals progress reliably from intake to confirmed attachment and service connection.
This role complements existing administrative, intake, and digital referral functions by focusing on complex navigation, warm handoffs, partner engagement, and community-facing system integration.
Key Responsibilities
1. Community Integration & Outreach
- Build and maintain collaborative relationships with:
- Primary care providers and clinics
- Hospital and ED/discharge teams
- Ontario Health / HCC partners
- Community support agencies and social service organizations
- Settlement and newcomer-serving agencies
- Promote awareness of OHT attachment pathways and team-based supports.
- Serve as a consistent point of contact for partners navigating referral and attachment processes.
- Support development and maintenance of referral resources, escalation pathways, and partner maps.
2. End-to-End Navigation & Attachment Support
- Provide proactive navigation support from referral/intake through confirmed outcome.
- Support unattached residents, including:
- High ED users
- Newcomers and refugees
- Individuals experiencing housing instability or other barriers
- Conduct follow-up outreach with residents and referring partners to prevent referral drop-off.
Ensure referrals progress from intake appointment- confirmed attachment.
- Escalate complex or stalled cases and support timely resolution.
3. Warm Handoffs & Referral Coordination
- Facilitate coordinated transitions between:
- Hospital discharge teams and primary care
- Primary care and community/social supports
- Primary care and IPCT services
- Ensure referrals include appropriate documentation, consent, and minimum data requirements.
- Confirm patient engagement and service initiation.
- Liaise with partners to troubleshoot intake barriers and communication gaps.
4. Intake & Segmentation Support
- Support implementation and operationalization of patient intake and segmentation processes.
- Assist in reviewing intake information and aligning residents to the most appropriate attachment pathway.
- Support triage and coordination for complex or high-needs residents requiring integrated attachment planning.
5. System Improvement & Reporting
- Identify recurring system gaps, bottlenecks, and workflow challenges.
- Contribute to development of navigation tools, referral guides, scripts, and process improvements.
- Maintain documentation related to navigation episodes, escalations, and outcomes.
- Participate in operational meetings and provide regular reporting on volumes, outcomes, and emerging issues.
Qualifications & Experience
Required
- Current registration in good standing with the College of Nurses of Ontario (CNO)
- Registered Nurse (RN) designation
- Minimum 3–5 years of relevant experience in healthcare, care coordination, navigation, primary care, hospital, or community-based services
- Demonstrated experience working across sectors including primary care, hospital, community, and social services
- Strong understanding of Ontario healthcare and community support systems
- Experience supporting vulnerable, marginalized, and complex populations
- Excellent communication, relationship-building, and stakeholder engagement skills
- Strong organizational, coordination, and problem-solving abilities
- Ability to work independently within a collaborative and evolving environment
Preferred
- Experience in system navigation, discharge planning, or integrated care coordination
- Knowledge of Ontario Health Teams and primary care attachment initiatives
- Experience with referral management systems and digital health tools
- Fluency in additional languages is considered an asset
Key Competencies
- Relationship-centred approach
- Systems thinking and collaboration
- Critical thinking and escalation management
- Equity, inclusion, and cultural humility
- Initiative and adaptability
- Strong accountability and follow-through
Working Conditions
- Hybrid/community-based role with regular engagement across partner organizations and sites
- Flexible scheduling may occasionally be required to support operational priorities
If you are seeking an opportunity to demonstrate your passion for excellence in a supportive work environment, we’d like to hear from you!
This job posting is for a new vacancy.
Use of Artificial Intelligence (AI) in Recruitment
At CHATS, our recruitment process consistently prioritizes people. AI tools may be employed for interview note-taking and summarizing; however, every application and interview are thoroughly reviewed by our hiring team before making any hiring decision. We are committed to leveraging technology responsibly and upholding fairness, transparency, and respect throughout all stages of recruitment.
About CHATS
Since 1980, CHATS has been a leader in providing home and community services for seniors and caregivers across York Region and South Simcoe. Each year, we support more than 8,100 older adults and caregivers through a wide range of community-based programs.
At CHATS, we are guided by a client- and family-centered approach rooted in compassionate, relationship-based care—empowering older adults to live safely and independently in their homes and communities.
We are proud to foster an inclusive, accessible, and supportive workplace where employees can grow, contribute, and make a meaningful impact every day.
Our Commitment to Equity & Accessibility
CHATS is an equal opportunity employer committed to building a diverse, inclusive, and accessible workplace. We welcome applications from all qualified individuals and provide accommodations throughout the recruitment process in accordance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code. Our recruitment and hiring processes will be modified to accommodate disabilities, upon request.
We thank all applicants for their interest, only those selected for an interview will be contacted.
