OHT Primary Care Integration & Intake Navigator - RN
About The Position
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. 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.
Requirements
- 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
Nice To Haves
- 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
Responsibilities
- 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.
- 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.
- 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.
- 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.
- 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.
Benefits
- Supportive work environment
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
