Clinical Assistant-Hospital to Home

Job Description

The Clinical Assistant, Hospital to Home provides administrative and coordination support to the manager, supervisor, and the multidisciplinary team as clients transition from hospital to home. The role helps ensure referrals, service orders, records, and communications are processed accurately, so care can begin safely and without avoidable delay. Working within established policies, privacy requirements, and role boundaries, the Team Assistant manages a high volume of information and inquiries, maintains complete records, coordinates information flow, and promptly escalates clinical, safety, service, or capacity concerns to the appropriate team member.

We are looking for:A Full-Time Permanent Clinical Assistant, Hospital to Home

Hours of Work:Monday – Thursday: 8:30AM to 4:30PM, Friday: 8:30AM to 3:30PM. This is a hybrid work from home role.

Reports to:Manager, Hospital to Home and Clinical Programs

Compensation

Hiring Salary Range: The salary for this role ranges from $39,000 to $55,000 per year, depending on your skills and experience.

Circle of Care Benefits:

Hybrid Environment: This is a hybrid position, with a mix of 3 in-office work and 2 work-from-home days, offering a balanced hybrid schedule. Our main office at 4211 Yonge Street has subsidized underground parking and is located conveniently on the subway line and GO transit. 

Health and Dental Benefits: A robust benefits plan with comprehensive health, dental, paramedical and vision coverage with employer paid premiums to support you and your family through all stages of life. 

Retirement Savings Plan: As part of our commitment to your long-term well-being, we provide an RRSP program through RBC with employer and voluntary employee contributions.  

Learning and Development: We support your continued growth and learning through paid training and professional development opportunities throughout your career.

Responsibilities

Referral Intake and Transition Support

• Enter, update, and maintain client, referral, service, and transition information in electronic databases and program trackers with accuracy, timeliness, and completeness.
• Track referral status, anticipated discharge dates, service start dates, outstanding tasks, and required follow-up.
• Review program trackers to identify clients approaching transition or discharge from the Hospital to Home program.
• At week six, notify the clinical team of upcoming discharges and the requirement to complete Transfer of Accountability documentation.
• Prepare Ontario Health atHome discharge and transition packages, ensuring required information is complete and ready for submission.
• Securely submit Ontario Health atHome discharge and transition packages using approved processes and document each submission.
• Confirm the client’s discharge from the Hospital to Home program and the start date of ongoing Ontario Health atHome services.
• Record confirmed discharge and service-start information in the appropriate program tracker.
• Identify missing information, discrepancies, delays, or potential service gaps and escalate unresolved concerns to the appropriate clinician or supervisor.
• Support timely and coordinated transitions from Hospital to Home services to ongoing community-based services.
• Communicate routine referral and transition information with hospital partners, clients and families, internal teams, and approved service providers within the scope of the role.

Team Coordination and Communication

• Provide daily administrative support to the Program Manager, Program Supervisor, and other Hospital to Home team members.
• Monitor assigned work queues, email, voicemail, and task lists to support timely follow-up and completion of assigned work.
• Prepare client lists, huddle materials, meeting minutes, action items, and other administrative materials as required.
• Assist with coordinating meetings, and other program activities as directed.
• Respond to routine inquiries from clients, caregivers, hospital teams, clinicians, and service providers within the scope of the role.
• Direct clinical questions, complex concerns, or matters outside the Team Assistant’s authority to the appropriate clinician, supervisor, or program lead.
• Prepare and securely send Primary Care Provider notifications and updates supplied by nurses or the Program Supervisor. Confirm transmission and track outstanding responses as required.
• Notify the appropriate clinician or supervisor of changes that may affect discharge, transition planning, service delivery, or client safety.
• Maintain clear, timely, and professional communication with internal and external partners.
• Participate in team meetings, orientation, training, emergency preparedness activities, and Support reconciliation of information across source documents, clinical records, and program trackers.

Records, Trackers, and Reporting

• Maintain accurate and timely client records, clinical trackers, program trackers, and other assigned monitoring tools.
• Complete routine data entry and updates across assigned systems and trackers and review entries for completeness, consistency, and accuracy.
• Scan, upload, label, distribute, and file client and program records so information is accessible to authorized team members when required.
• Monitor outstanding and overdue health-record returns against established timelines.
• Enter health-record return information into the Hospital to Home tracker following updates from the Records Management team.
• Follow up with clinicians regarding overdue health-record returns and document follow-up attempts.
• Escalate unresolved, repeated, or high-risk health-record return concerns to the Program Manager or appropriate supervisor.
• Maintain the clinical tracker, volunteer survey tracker, and other assigned program-monitoring tools.
• Track Medical Equipment and Supplies orders and utilization for program monitoring and reporting.
• Reconcile information across source documents, clinical records, and program trackers and identify missing, duplicate, inconsistent, or potentially inaccurate information.
• Track assigned program indicators, including referral volumes, response times, incomplete referrals, service-start status, and outstanding follow-up.
• Extract, compile, review, and validate program data for monthly, quarterly, annual, and Ontario Health reporting using established definitions and quality checks.
• Work with the Quality team to reconcile data, investigate discrepancies, and prepare supporting information for quality reports and improvement initiatives.
• Provide Program Managers with validated data and supporting documentation for program monitoring, chart audits, and operational reviews.
• Assist with compiling objective records and performance data for performance-management processes at the direction of the Program Manager while maintaining confidentiality and appropriate role boundaries.
• Support audits, data validation, incident follow-up, reporting, and quality-improvement activities by gathering accurate information and maintaining organized documentation.
• Identify recurring documentation, system, or workflow issues and bring forward practical improvement opportunities to the appropriate supervisor or program lead.

Risk, Health and Safety Management

• Identify and promptly report safety concerns, incidents, service gaps, and urgent issues through established organizational procedures.
• Escalate urgent, high-risk, or client-safety concerns immediately to the appropriate clinician or supervisor.
• Document information accurately and objectively within the Team Assistant’s assigned access, responsibilities, and scope.
• Protect personal health information and use approved secure methods when collecting, accessing, transmitting, storing, or discussing client information.
• Follow organizational privacy, confidentiality, records-retention, occupational health and safety, infection prevention and control, accessibility, and emergency-management requirements.
• Complete required health, safety, privacy, emergency preparedness, and organizational training.
• Identify documentation discrepancies, duplicate records, system issues, or workflow risks and take appropriate corrective or escalation action within the scope of the role.
• Share observed risks, service gaps, and opportunities to improve safe, reliable, and efficient program

Qualifications

• Certificate in health administration, medical office administration, business administration, social services, or an associated field. An equivalent combination of education and relevant experience may be considered.
• 1+ year of administrative, intake, scheduling, customer service, or coordination experience in health care or a similarly complex setting is preferred.
• Experience with hospital discharge, transitional care, community care, or multidisciplinary teams is an asset.
• Experience using electronic client records, referral systems, Microsoft 365, and protected communication tools is preferred.
• Strong organizational skills, attention to detail, and the ability to manage competing priorities in a busy setting.
• Clear written and verbal communication skills, sound judgment, and the ability to recognize when a concern needs to be escalated.
• Ability to maintain confidentiality and work independently while collaborating with a multidisciplinary team.