Care Coordinator (Community Care)

Location: Singapore
Job Type: Permanent
Reference: JO-2106-12231

Salary: Up to $4,000 / month

Nearest MRT: Queenstown

Working hours: Monday - Sunday (Shift work according to supervisors)


Job Responsibilities:

  • Attends to queries receive via an integrated telephone hotline that forms a network for triaging patients, and provides an avenue to caregivers and community partners to connect with the client for information relating to the health and well-being of patients and clients within the selected community.
  • Recruit high risk patients through Multiple Disciplinary Meetings, referrals, screenings
  • Triage and assess patient's medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
  • Synthesize assessment information to prioritize care needs and develop care plan goals together with patient, family/caregiver and the community care team.
  • Implement appropriate care coordination and transitional case management; and evaluate the outcomes accordingly.
  • Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient’s community. Coordinate the necessary referrals accordingly and in a timely manner.
  • Provide a valuable link by ongoing collaboration among the patients, families/caregivers and the multidisciplinary teams on a timely basis.
  • Conducts follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.
  • Promote and guide positive changes in patient’s lifestyle in the community.
  • Monitor patient’s general medical condition during home visit and report to patient’s Principal Doctor or primary care provider and/or community partner where necessary.
  • Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.
  • Document assessments, plans, and outcomes promptly and accurately in the relevant system. 
  • Maintain high level contact with step-down facilities.
  • Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient’s best interests.
  • Station in community healthcare posts when needed, where patient/ residents can be cared for conveniently within their community.
  • Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.
  • Participate in projects and/or community events organized by the client or partners within the selected community.
  • Any other duties as assigned by Reporting Officer.

Job Requirements:

  • Minimum qualification: Degree or equivalent professional qualifications in Nursing, Social Work or Allied Health.
  • 3 – 5 years of experience in nursing or related field in acute and/or community setting in Singapore is preferred.
  • Knowledge in geriatric and community care will be an advantage.
  • Strong team-player, with natural ability to interact with healthcare staff and community partners of all levels.
  • Organized, analytical, able to fit different pieces of the puzzle together.
  • Pleasant disposition, approachable, with strong interpersonal and relational skills.
  • Good verbal and written communication skills.
  • Ability to use local languages and dialects will be an advantage, especially coupled with experience interacting with and managing patients and caregivers.
  • Independent worker, with strong initiative.
  • Comfortable with ambiguity, unchartered territory, enjoy challenges and problem solving.
  • Equipped with basic computer skills in MS Words, Excel and PowerPoint.
  • Experience and ability to work shifts may be an advantage for specific roles within the team.