$77,036.00 To $105,925.00 Annually based on qualifications and experience.Registered Nurse Care Coordinator position is available as either Permanent Full-time (35 hours per week) or Permanent Part-Time (21 hours per week).JOB SUMMARYReporting to the Health and Wellness Director, the RN Care Coordinator is responsible for supporting clients in developing, maintaining, and/or regaining their sense of wellbeing and independence at home and in the community.DUTIES AND RESPONSIBILITIESProviding Home Care Nursing ServicesUsing a trauma-informed approach, promotes a culturally safe and therapeutic care environment in support of client self-advocacy and self-determinationPerforms comprehensive environmental assessment of the home, along with a thorough evaluation of client’s physical, cognitive, and psychosocial functioning to identify barriers to healthProvides home care nursing assessment and nursing care throughout the adult and older adult health trajectory, including chronic disease management, wound care therapy, and end-of-life palliative assessment and nursing careUpon identifying client goals and needs, tailors individualized care plans in consultation with clients, their families, and members of the interdisciplinary team, providing joint home visits with other team members as neededImplements evidence-informed interventions that respect self-determination, strengthen self-management, and bolster engagement in meaningful activities, while supporting family and caregiver capacityMaintains accurate documentation and reporting of outcome measures consistent with TWN policy and professional standards of practiceUsing a trauma-informed approach, promotes a culturally safe and therapeutic care environment in support of client self-advocacy and self-determinationCare Coordination & Caseload ManagementWith cultural sensitivity and humility, fosters care relationships with clients and their self-identified families and support persons to help establish rapport, trust, and mutual respectAssesses client’s health and functional status, along with their informal support network, and bolsters integrity of supports as needed, by way of advocacy, shared care planning, and integration of additional formal supports and resourcesPromotes client independence, participation, and wellness by using a care coordination process of client assessment, care planning, implementation, and ongoing evaluation and re-assessment as neededProvides direction to home support staff by creating client-specific home support service plans which delegate home support service tasks in support of client independence with their iADLs and ADLsMonitors and evaluates both clinical care plans and home support service plans to ensure optimal and effective care deliveryInitiates and participates in care conferences with clients, families, interprofessional team members, and service providers to help ensure a coordinated and integrated approach to client careSupports clients’ access to health services and helps clients and families navigate resources and overcome personal and systemic barriers to accessing care and achieving health & wellnessEffectively consult and confer with various team members in support of interdisciplinary collaboration and shared care planningSupporting Continuity of CareAnticipates medical and functional changes over time, especially in the context of serious illness or chronic disease and provides avenues for early engagement and conversations with clients and families to ensure care planning is guided by clients’ and families’ goals, wishes, and valuesEnsures continuity of care over time and with any changes in client condition, including hospitalizationEffectively addresses systemic barriers to ensure seamless care transitions, improve access to care services, and support continuity of care, engaging closely and collaboratively with all internal and external partnersFacilitates safe and effective transitions of care between hospital and home by liaising with the acute care team throughout the hospital stay, and ensuring effective and timely communication and follow-up post hospital dischargeIdentifies community and cultural resources, assists clients in accessing benefits or supports, and advocates for equitable, client-centered servicesCoordinates ongoing care as well as access to TWN specific programming such as primary care, mental wellness, recreation, housing, etc. and supports referrals to external health and community services as neededSupporting Community Health & WellnessGuided by the vision, goals, and strategic plan of Tsleil-Waututh Nation, supports population-wide initiatives to augment client, family, and community wellbeingSupports community preventative and proactive care and education initiatives and workshops that support health and wellnessActs as a clinical resource for the interdisciplinary team by providing information based on nursing theory and practice as related to clients with complex health care needsProvides education to home support staff on topics like supporting palliative care clients in the home, medication management, dementia care, etc.Liaises with Indigenous Elders, Healers, and Knowledge Keepers to foster connection, cultural engagement, and strength-based healing & recoveryContributes to community wellness programming, prevention initiatives, and outreach efforts that strengthen the community’s social determinants of healthContributes to continuous quality improvement by identifying gaps in community services and resources, and participates in program planning and developmentEnsuring Continuous Education & Professional DevelopmentEngages in ongoing learning opportunities to support continuing education and professional developmentStays current and pursues continuous professional development by attending conferences, caucuses, events, and symposia on Indigenous health and wholistic wellness as requested by the DirectorUpholds best practice standards in nursing care and is deeply committed to excellence, consistency, and continuous improvement in professional and ethical conductPerforms other home care nursing & care management duties as assigned by the Director.QUALIFICATIONSRequired qualificationsCurrent practicing registration that is in good standing, as a Registered Nurse (RN),



with the British Columbia College of Nurses and Midwives (BCCNM)Graduation from an approved School of Nursing with a Bachelor’s Degree in NursingA minimum of 3 to 5 years of relevant professional experience including home care nursing, case management, interdisciplinary team collaboration, and palliative careValid BC Driver’s License – Class 5Reliable vehicle and current vehicle insuranceBasic Life Support (BLS) certificationDocumentation of immunization and TB screening historyAble to lift up to 25 poundsPreferred QualificationsCompletion of Indigenous Cultural Safety and Humility training (e.G. San’yas)Experience working within or alongside First Nations communities or Indigenous-led health organizationsKNOWLEDGE, SKILLS, & ABILITIESBroad and comprehensive knowledge and expertise in nursing assessment, care planning, care management, and care evaluationSelf-directed with demonstrated organizational skills, working independently, and in collaboration with othersProven ability to use tact and sound judgment in decision-making, and when dealing with sensitive and complex issuesDemonstrated ability in maintaining strict confidentialityDemonstrates professional accountability, integrity, and humility in clinical practiceDemonstrated knowledge and skills in care coordination, case management, clinical consultation, and care conferencingExceptional oral and written communication, conflict resolution, and de-escalation skills, which effectively support meaningful connection, interpersonal relations, and collaborative team dynamicsDeeply self-aware, reflective, and emotionally grounded, demonstrating a genuine, kind, and gentle approach in relating to others, offering compassion and care to support the well-being of clients and their family membersAbility to make effective referrals, identifying gaps in services and reflecting an in-depth knowledge of community resources and strong team-oriented skills in working with other community partnersAbility to continue to strongly advocate for and support clients, while being witness to the ongoing impacts of systemic racism and population health disparitiesBrings a strong ethic of client service and is knowledgeable about the cultures and traditions of diverse Indigenous NationsHigh level of emotional intelligence, integrity, and patienceWORKING CONDITIONSPhysical DemandsIntermittent physical activity including walking, standing, sitting, lifting and supporting clients.May be exposed to occupational hazards such as infectious waste, diseases and chemicals.Manual dexterity required to use desktop computer and peripherals.Mental FocusMay deal with individuals who can, from time to time, be demanding and challenging. Must be able to remain patient and calm, and may have to engage in conflict resolution.Environmental ConditionsThe noise level is generally quiet, but at times noise could elevate.Must be able to work relatively independently and deal with issues of personal safety because this position is outside the controlled environment of a hospital.#J-18808-Ljbffr

📌 Registered Nurse Care Coordinator - $77,036 - $105,925 A Year - Part Time (Winnipeg)
🏢 Tsleil-Waututh Nation
📍 Winnipeg