Position Summary:

The Care Coordinator is a member of Orca Lelum’s Care Team Specialists. The Care Team Specialist are led and supervised by the Care Team Manager and works collaboratively to provide coordinated, interdisciplinary services to young spirits throughout the 10-Week Wellness Program. The Care Coordinator is responsible for coordinating the young spirit's journey through Orca Lelum's 10-Week Wellness program, with primary accountability for intake, collaborative care planning, safety, care, and supervision, and discharge/transition planning. The position provides trauma-informed, culturally grounded social work support and serves as a central point of coordination among the young spirit, family or caregivers, referring and community professionals, and Orca Lelum's interdisciplinary team. The role conducts psychosocial and safety screening, supports disclosures and crisis response, coordinates referrals and services, maintains required documentation in AMIS, and helps ensure each young spirit's care plan is individualized, strengths-based, culturally rooted, trauma-informed, holistic, and responsive to their evolving needs and goals. The role also leads discharge and transition planning, ensuring planning begins early, reflects the young spirit’s voice and identified needs, and supports a coordinated transition from Orca Lelum to family, community, Nation, health, social-service, cultural and other ongoing supports, with appropriate referrals, follow-up and continuity-of-care arrangements in place.

Core Accountabilities:

1. Intake, Admission & Engagement

- Serve as a primary point of contact for young spirits, families/caregivers, referring professionals, and community partners throughout the intake and admission process.
- Coordinate intake interviews, facility tours, required forms, supporting documentation, and communication with internal and external partners.
- Conduct psychosocial screening and gather information regarding strengths, goals, lived experiences, family and community context, housing, education, child welfare or justice involvement, mental health, substance use, safety concerns, and existing supports.
- Compile and bring forward intake findings and relevant supporting information to Orca Lelum’s Screening Panel for review and determination of whether the young spirit is accepted into the 10-Week Wellness Program. Ensure the Screening Panel has sufficient information to make an informed decision regarding program fit, readiness, safety, care and supervision needs, and Orca Lelum’s capacity to appropriately support the young spirit.
- Document the Screening Panel’s admission decision and any conditions, recommendations, identified supports or follow-up actions arising from the screening process, and ensure these are communicated to the appropriate individuals.
- For young spirits accepted into the program, ensure intake findings, including strengths, risks, goals, safety, care and supervision needs, family perspectives, professional recommendations and any direction arising from the Screening Panel are communicated to the relevant interdisciplinary team and incorporated into initial and ongoing Care Planning.
- Where a young spirit is not accepted, support timely and respectful communication of the decision in accordance with Orca Lelum’s established processes and coordinate any identified referrals, recommendations or transition to alternative services within the scope of the Care Coordinatorrole.
- Collaborate with Care Team Specialists, Youth Support, Cultural Support, clinical, and other external partners to support a safe, timely, trauma-informed and culturally respectful admission process.
- Build rapport with each young spirit and their supports so that intake establishes a explicit foundation for Care Planning and participation in the program.

2. Young Spirit Safety, Care & Experience

- Together with the Care Team Manager and Program Director, contribute to the oversight and coordination of the safety, care, supervision and Care Planning of assigned young spirits within the scope of the Care Coordinator role.
- Maintain awareness of significant changes in each assigned young spirit’s wellness, behaviour, adaptive functioning, participation, relationships, safety, substance use, mental wellness or program engagement and ensure relevant information informs Care Planning and team response.
- Ensure Care Plans accurately reflect identified safety, care, supervision and therapeutic needs, including approved support or safety plans where required.
- Work collaboratively with other Care Team Specialists and other teams, including Youth Support, Cultural Support, Nursing supports, who are responsible for frontline care, supervision and day-to-day implementation of established Care Plans, to ensure relevant Care Plan information and changes are clearly communicated.
- Support young spirits to express their needs, hopes, thoughts, feelings, interests and goals and ensure their voice meaningfully informs Care Planning and service delivery.
- Promote coordinated, strengths-based, developmentally appropriate, trauma-informed and culturally grounded support from intake through graduation or early transition.
- Ensure concerns raised by young spirits and families are heard, documented, addressed within the Care Coordinator’s role and escalated appropriately.
- Support and follow established urgent and emergency procedures, including child-safety, missing-young-spirit, medical-emergency and incident-response procedures.

3. Individualized Care Planning & Coordination

- Facilitate and coordinate the development and ongoing review of individualized Care Plans for assigned young spirits in collaboration with the young spirit and interdisciplinary team, and coordinate communication and follow-through to support their consistent implementation across the program.
- Ensure Care Plans are timely, individualized, strengths-based, culturally rooted, trauma-informed and holistic and meaningfully reflect the young spirit’s voice, goals, strengths, needs, interests, progress, risks, supports and priorities.
- Facilitate weekly interdisciplinary Care Planning for assigned young spirits, ensuring relevant team members have opportunities to contribute observations, assessments, recommendations,



progress updates and identified needs from their respective areas of responsibility.
- Ensure intake findings, family and community perspectives, counselling and therapeutic recommendations, cultural goals, relevant medical or regulated-professional direction, frontline observations and other significant information are appropriately considered within Care Planning.
- Ensure Care Planning meaningfully integrates relevant observations, assessments, recommendations and perspectives from the interdisciplinary team, including Youth Support, Cultural Support, Counsellors, the Youth Advocate & Mentor, medical and clinical providers, and other professionals or supports involved in the young spirit’s care. Ensure young spirit voice remains central to this process, including through direct engagement with the young spirit and relevant advocacy and relational insights brought forward by those working closely with them.
- Work collaboratively with the interdisciplinary team to identify individualized opportunities for wellness, mentorship, recreation, cultural connection, therapeutic support and community engagement that are responsive to each young spirit’s identified strengths, needs, interests and goals.
- Work with the Program Administrative Assistant, who provides administrative support to Care Planning meetings by capturing meeting minutes, decisions, assigned actions and follow-up items. Review the substantive Care Planning record as required to ensure decisions and actions affecting assigned young spirits are accurately understood and reflected in their Care Plans.
- Ensure relevant Care Plan updates are shared and communicated with the staff and professionals responsible for carrying out their respective components of the plan, including other Care Team Specialists, Youth Support and Cultural Support as key frontline contributors to the young spirit’s day-to-day care, supervision, relational support, cultural support and programming.
- Track agreed actions, referrals, recommendations and follow-up requirements; monitor overall follow-through on the Care Plan; and bring outstanding, unresolved or emerging needs back to the appropriate team member, interdisciplinary team or Care Team Manager.
- Coordinate services, referrals and interdisciplinary follow-up arising from the Care Plan within the Care Coordinator’s scope to support continuity and integration of care.
- Identify repeated gaps in Care Plan follow-through, unresolved interdisciplinary issues or significant barriers to meeting a young spirit’s identified needs and work with the relevant team or professional to support resolution, escalating significant or persistent concerns to the Care Team Manager.

4. Social Work Support, Disclosures & Safety Planning

- Respond to young spirit disclosures involving trauma, abuse, neglect, exploitation, violence, self-harm, unsafe living situations, or other significant concerns with compassion, grounding, and appropriate follow-up.
- Support young spirits in understanding their rights, choices, available supports, and limits to confidentiality, including duty-to-report obligations.
- Consult with the Care Team Manager, Program Director and relevant team members when disclosures require escalation, reporting or additional support.
- Fulfil applicable professional and legal child-protection and duty-to-report obligations and ensure significant matters are promptly communicated through Orca Lelum’s established escalation pathways.
- Support young spirits during emotional distress or crisis using de-escalation, stabilization, and trauma-informed approaches within the scope of the position.
- Collaborate with young spirits and relevant interdisciplinary team members to develop and coordinate appropriate safety plans in response to suicidal ideation, emotional crisis, heightened safety concerns or other identified risks, seeking consultation where required to address medical concerns, trauma-informed approaches, or integrating cultural support.
- Identify when emergency or additional professional supports are required and follow established organizational protocols.

5. Case Coordination, Advocacy & Family/Community Collaboration

- Serve as a central case-coordination contact for assigned young spirits and support effective communication among the young spirit, family/caregivers, Nation, referring professionals, community providers and Orca Lelum team.
- Support young spirits in navigating systems including child welfare, education, housing, justice, income assistance, health care, mental health/substance use services, and community supports.
- Advocate for young spirit needs while centering their voice, consent, dignity, cultural identity, and best interests.
- Support meaningful family/caregiver involvement in Care Planning, transition and continuity of care, as appropriate and consistent with the young spirit’s circumstances, consent and privacy requirements.
- Participate in family, case, and transition meetings and collaborate with the other Care Team Specialists and interdisciplinary team members to strengthen continuity of care.

6. Discharge, Transition & Continuity of Care

- Lead discharge and transition planning for assigned youth, beginning at intake to support a coordinated and supported transition from Orca Lelum.
- Work with the young spirit and interdisciplinary team to identify post-program goals, safety considerations, family/community supports, appointments, referrals, cultural connections, education or housing needs, and other continuity-of-care requirements.
- Coordinate discharge planning with other Care Team Specialists, the interdisciplinary team and with families/caregivers, Nations, referring agencies, and other community supports to develop a coordinated, realistic and individualized transition plan.
- Ensure referrals, appointments, follow-up actions, required documentation,



and responsible parties are identified and communicated before discharge.
- Prepare discharge summaries, after care planning documentation and ensure relevant information is incorporated into the young spirit's discharge/transition record.
- Ensure the young spirit and appropriate family/caregivers or community supports understand the transition plan, upcoming appointments, referrals and available aftercare supports.
- Coordinate the transition from discharge planning into Orca Lelum aftercare, ensuring aftercare activities are connected to identified wellness goals, safety considerations, referrals and community supports.
- Bring concerns regarding a planned graduation, self-exit, early exit, discharge destination, continuity of care or transition safety to the Care Team Manager promptly. Decisions regarding involuntary or organizationally initiated exits are made through the established organizational decision-making process.

7. Documentation, AMIS & Reporting

- Maintain accurate, timely, objective, and confidential documentation throughout intake, care planning, service coordination, safety planning, and discharge.
- Ensure required information, case notes, referrals, disclosures, safety plans, care-plan updates, and discharge information are documented in AMIS in accordance with organizational policies, procedures, privacy requirements, and professional standards.
- Maintain intake forms, enrolment packages, assessments, supporting documentation and discharge/transition records.
- Track outstanding documentation, referrals, actions, and follow-up requirements across the young spirit's continuum of care.
- Bring repeated documentation gaps, service barriers, unresolved actions or emerging patterns to the Care Team Manager.
- Contribute feedback and recommendations to improve intake, Care Planning, documentation, discharge and other Care Coordinator processes.

8. Cultural Safety & Trauma-Informed Practice

- Practice with cultural humility and respect for Indigenous identities, histories, families, Nations, community contexts, values, and cultural practices.
- Recognize the impacts of colonization, intergenerational trauma, systemic inequities, and disrupted family/community connections on young spirits and families.
- Use a decolonial, trauma-informed and relational approach that promotes safety, choice, collaboration, trust, dignity, connection, and young spirit voice.
- Work respectfully with Elders, Knowledge Keepers, Cultural Support team, and community partners and support the integration of cultural goals and supports into care planning.
- Commit to ongoing learning, reflective practice, and culturally safe practice.
- Support the integration of cultural identity, connection, goals, practices and supports into individualized Care Plans.
- Follow established cultural protocols and seek guidance from the Cultural Support Team and Care Team Manager where questions regarding cultural practice, protocol or integrity arise.

9. After-Hours Support

- Participate in the after-hours rotation, providing timely support and guidance to staff in the event of emergencies, urgent matters, significant young spirit care concerns, or other situations requiring escalation, in accordance with established after-hours and escalation procedures.
- Provide after-hours support primarily by telephone and text to assist staff in responding to emerging concerns, maintaining continuity of care, and determining appropriate next steps.
- Attend Orca Lelum in person when circumstances require additional onsite support, including situations where an employee is unexpectedly unable to report for or complete a scheduled shift and immediate staffing support is necessary, or where additional staff support is required when accompanying a young spirit to the emergency department or another urgent health-care service.
- Ensure significant after-hours incidents, decisions, actions, and follow-up requirements are appropriately communicated and documented in accordance with organizational policies and procedures.

Qualifications & Requirements:

- Bachelor's or Master's degree in Social Work (BSW/MSW)
- Registration in good standing with the BC College of Social Workers (BCCSW), or eligibility for registration is an asset
- Minimum 5 years of experience working with youth in mental health, substance use, trauma, child welfare, crisis response, residential care, or a related setting
- Demonstrated knowledge of child protection legislation, duty to report, confidentiality, informed consent, and ethical social work practice
- Experience with assessment, care planning, case coordination, referrals, transition/discharge planning, and interdisciplinary collaboration
- Valid Class 5 BC Driver's Licence
- Valid First Aid Certificate (Emergency First Aid - Community Care), or ability to obtain as required
- Consent to required criminal record and prior contact checks
- Proficiency with standard computer applications and client database systems; experience with AMIS is an asset
- Knowledge of Coast Salish teachings and experience working with Indigenous communities are assets.

Skills & Attributes:

- Strong professional judgment, organization, follow-through, and attention to detail.
- Ability to build trusting, respectful relationships with young spirits, families, and community partners.
- Calm, grounded, compassionate approach during crisis and emotionally complex situations.
- Strong written communication and documentation skills.
- Ability to coordinate multiple care needs, timelines, referrals, and team responsibilities.
- Ability to work independently while collaborating effectively within an interdisciplinary team.
- Strong understanding of trauma-informed, culturally safe, strengths-based, and youth-centred practice.
- Commitment to Indigenous-led wellness and holistic approaches to healing.
- Ability to handle sensitive information with discretion and confidentiality.

Additional Terms:

- This job description is not intended to be all-inclusive. The employee may perform other related duties as required to meet the ongoing needs of the organization.
- The hours of work, including days off, may be subject to change to match the operational requirements.
- Qualified First Nations candidates will be given preference in accordance with the BC Human Rights Code section 42

Pay: $46.36 per hour

Expected hours: 35.0 per week

Work Location: In person

📌 Care Co-ordinator (Canada)
🏢 Orca Lelum
📍 Canada