Referrals Coordinator, Social Medicine

Position Summary

The Social Medicine Referrals Coordinator provides clinical-operational leadership in coordinating equitable access to Social Medicine services for patients with complex medical, psychosocial, and health equity needs. As an integral member of the interprofessional team, the Referrals Coordinator is responsible for implementing, coordinating, monitoring, and evaluating referral pathways and care transitions across the health and social care continuum. The role functions as a key liaison between patients, families, healthcare providers, community organizations, and system partners to facilitate timely, integrated, and patient-centred care. The Referrals coordinator exercises independent judgment in assessing referral appropriateness, addressing barriers to access, resolving complex service navigation issues, and facilitating seamless transitions between hospital, community, and social service systems. The Social Medicine Referrals Coordinator provides subject matter expertise, operational leadership, and consultation regarding referral management processes, access optimization, health equity initiatives, community partnerships, quality improvement, and performance measurement. The role contributes to program planning, service development, and system improvement initiatives aimed at advancing access to care and improving outcomes for marginalized and structurally vulnerable populations.

Duties

Coordinate and implement patient-centred care plans with patients, families, caregivers, and the interprofessional team to support seamless transitions across the continuum of care and community services
Coordinate complex referrals and facilitate equitable access to health, social, housing, and community services
Assess referral appropriateness, identify barriers to care, and develop strategies to improve access to required supports and services
Serve as a clinical and operational resource on referral pathways, eligibility requirements, community resources, and access processes
Provide consultation, coaching, education, and guidance to clinical teams, learners, community partners, and referring providers on referral management and care coordination
Facilitate communication and collaboration among interdisciplinary teams and community organizations to support integrated care delivery
Support staff onboarding and ongoing education related to referral processes, Social Medicine services, and community resources
Identify and resolve referral, service access, and care coordination issues through collaboration and problem-solving
Assist with workload prioritization, referral coordination, and service allocation across program areas
Promote patient-centred, trauma-informed, anti-oppressive, and equity-focused approaches to care
Develop and monitor referral performance indicators, including service utilization, access targets, turnaround times, and patient outcomes
Collect, analyze, and report operational and referral data to support decision-making, program evaluation, planning, and quality improvement
Conduct audits and evaluations to identify trends, gaps, risks, and opportunities for improvement
Develop and maintain dashboards, reports, tracking tools, and performance metrics to support program accountability
Recommend and implement process improvements to enhance patient access, operational effectiveness, and care coordination
Monitor referral workflows and operational performance, escalating issues that may impact patient safety, service quality, or equitable access to care
Participate in quality improvement initiatives, program evaluations, and strategic planning activities
Build and maintain collaborative relationships with healthcare providers, community agencies, housing organizations, social service partners, and other stakeholders
Act as a liaison between Social Medicine services and external partners to support coordinated and integrated models of care
Contribute to service planning, resource allocation, and referral pathway development to address emerging patient and system needs
Support initiatives that improve access for marginalized, underserved, and structurally vulnerable populations
Represent the Social Medicine Program in committees, working groups, meetings, and community initiatives
Promote awareness and utilization of Social Medicine services among internal and external stakeholders
Provide leadership, consultation, and subject matter expertise in system navigation, community resources, social determinants of health, and equitable access to care
Contribute to program development, policy development, and organizational initiatives that advance Social Medicine and Population Health priorities
Foster a culture of collaboration, innovation, continuous learning, accountability, and excellence
Maintain current knowledge of emerging practices, legislation, and health system priorities relevant to the role
Participate in corporate committees, special projects, and organizational initiatives that support program and organizational effectiveness
Qualifications
Bachelors degree in health sciences, social services, community development, public health, social work, or related field or recognized equivalent required.
Experience working with patients experiencing marginalization, homelessness, substance use and mental health challenges.
Experience coordinating referrals or patient intake processes in health, community or social service settings.
Experience with the provision of trauma-informed care, harm reduction principles, and anti-racist, anti-discriminatory, anti-oppressive practices
Strong knowledge of, and familiarity with, community resources that address the social determinants of health
Strong understanding of acute care and community health settings and ability to navigate health systems an asset
Well-developed decision-making, problem-solving, and judgement skills
Experience developing community partnerships and collaborative service pathways.
Excellent interpersonal, oral, and written communication skills
Experience in program development and implementation
Experience analyzing operational data and preparing reports.
Effective time management, prioritization and organizational skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment
Proven ability to work as a team member and independently
Ability to have and use diplomacy and tact at all times
Knowledge of Epic an asset