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Job summary

The CMTL facilitates patient care management and transition planning from admission through discharge across the care continuum. They coordinate with interprofessional teams to ensure timely, sustainable discharge plans and provide leadership in developing care management policies.

Job details

Notice NOW ACCEPTING LATE INTERNAL APPLICATIONS: Please note that the internal competition for this position is now closed, however we are still accepting late applications from qualified internal candidates. Should you choose to apply, your application will only be considered after on-time internal applicants have been considered. minimum Nurse to Patient Ratios (mNPRs) Vancouver Coastal Health (VCH) is proud to be part of the provincial implementation of minimum Nurse to Patient Ratios (mNPRs), an initiative aimed at enhancing nursing practice and strengthening quality of care across the health system. mNPRs set the minimum number of nurses providing care to patients on a given unit. In British Columbia, mNPRs are developed in partnership with the Ministry of Health, the BC Nurses’ Union (BCNU) and health organizations. Guided by our values: We Care for Everyone, We Are Always Learning and We Strive for Better Results, we remain committed to fostering quality practice and learning environments where nurses can grow and thrive. Description JOB SUMMARY:Within the context of a patient and family-centred framework and continuum-based care model and in accordance with established standards of professional practice and the vision, values and policies of the organization, the Care Management Transition Leader (CMTL) facilitates patient’s care management and transition planning across the care continuum from admission through discharge. Coordinates and collaborates with the acute interprofessional team to expedite effective patient care and coordinates timely sustainable discharge plans. Conducts comprehensive nursing assessments, directs the interprofessional team on appropriate level of care and determines sustainable, quality discharge plans. Assesses and evaluates the clinical and functional status of the patient by coordinating both acute and community staff and resources to ensure the timely and safe discharge of patients. Plans and facilitates clinical discussions to support timely and safe patient discharges with care teams and other health care professionals by advising on availability and eligibility of community resources. Accountable for the development and effectiveness of policies, procedures and standards to support care management and discharge planning. Intervenes to address barriers and provides leadership to achieve optimal outcomes including securing funding and approvals for services as required. Ensures relevant assessments are completed to determine the appropriate treatment and make community referrals based on patient care needs and urgency. Provides education and consultation to the patient/family and coordinates the transition of the patient post acute care. This work is framed within VCH’s commitments to our pillars of Indigenous Cultural Safety, Anti-Racism, Equity, Diversity and Inclusion, and Planetary Health.QUALIFICATIONS:Education & ExperienceCurrent practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).Three (3) years’ recent, related clinical nursing experience across the care continuum (i.e. acute/community) including (1) year experience in a supervisory/leadership role responsible for patient care coordination, access and planning, case management and/or discharge planning, or an equivalent combination of education, training, and experience.Knowledge & AbilitiesComprehensive knowledge of Nursing theory and practice within a patient/family centered model of care across the care continuum.Comprehensive knowledge of the BCCNM standards for nursing practice.Broad knowledge of evidence-based nursing practice related to various patient population groups, acute and community care areas, and demonstrated ability to apply knowledge to a case management process.Broad knowledge of pathophysiology and pharmacology and demonstrated ability to apply knowledge to safely plan transition/discharge.Broad knowledge of biological and pathophysiology indicators related to severity of illness to apply medical appropriateness criteria to resource utilization and transition/discharge planning.Broad knowledge of the illness or disease process and potential long-term complications. Broad knowledge of other health care disciplines and their roles in patient care.Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment.Broad knowledge of external agencies and community resources.Demonstrated ability to engage in comprehensive assessment, observation and monitoring of patients.Demonstrated ability to plan, organize, and prioritize work in relation to unit and hospital access and flow needs.Demonstrated ability to analyze situations, problem solve, deal with conflict and negotiate resolutions in a timely manner.General knowledge of Trauma Informed Practice and Harm Reduction approaches and Strengths-based care.Demonstrated ability to promote Indigenous Cultural Safety. Demonstrated ability to provide competent and culturally safe care in a variety of settings and with diverse populations.Demonstrated ability to provide leadership, work direction and consultation.Demonstrated ability to work independently and as a member of an interprofessional team. Demonstrated ability to develop and maintain collaborative working relationships and communicate (verbally and in writing) effectively with patients and their families, coworkers, physicians, other health care staff, and staff of external agencies.Demonstrated skill in CPR Techniques.Ability to operate related equipment including applicable software applications.Demonstrated physical ability to perform the duties of the position. The hours of work including days off and work area may be subject to change consistent with operational requirements and the provision of the Collective Agreement and applicable statutes. Details At Vancouver Coastal Health, our vision of healthy lives in healthy communities inspires us and our values and pillars guide us. We support equitable practices, diverse teams and inclusive environments, which are vital to creating welcoming spaces where everyone can bring their whole selves to work and feel supported. We encourage applications from equity-deserving communities, including Indigenous Peoples and members of racialized groups, people with disabilities and people of all gender identities and expressions and sexual orientation.Vancouver Coastal Health is proud to be recognized as one of Canada’s Top 100 Employers, BC’s Top Employers, Canada’s Best Diversity Employers and Canada's Top Employers for Young People in 2026.Unless otherwise noted on the posting, internal job postings close at 8:00 AM Pacific Time on the listed Closing Date. Please submit your digital application via the Internal Career Portal prior to the Closing Date & Time.Nursing & LPN successful applicants will be notified by email.We regret that only short listed candidates will be acknowledged.This is an internal job posting for Vancouver Coastal Health employees only.

What you’ll do

The CMTL facilitates patient care management and transition planning from admission through discharge across the care continuum. They coordinate with interprofessional teams to ensure timely, sustainable discharge plans and provide leadership in developing care management policies.

Requirements

Requires current registration as a Registered Nurse with the BCCNM and at least three years of related clinical nursing experience. Candidates must have at least one year of experience in a supervisory or leadership role related to patient care coordination or case management.

Listed skills

• Clinical care · Preferred
• collaborative · Preferred
• assessment · Preferred
• Leadership · Preferred
• staff · Preferred
• Health · Preferred
• Teams · Preferred
• Planning · Preferred
• management · Preferred
• case management · Preferred
• Time · Preferred
• coordination · Preferred

Other relevant skills

Identified from the job description. Confirm important requirements above.

• Patient Care Coordination
• Discharge Planning
• Case Management
• Nursing Assessment
• Interprofessional Collaboration
• Clinical Leadership
• Resource Utilization
• Trauma Informed Practice
• Harm Reduction
• Indigenous Cultural Safety
• CPR Techniques
• Conflict Resolution
• Patient Advocacy
• Clinical Pathways
• Care Transition Planning

Job areas

• Healthcare
• Management & Leadership