City of Lakes Family Health Team Social Worker / Patient Navigator

Job Description

Location: City of Lakes Family Health Team has 4 sites throughout the region including sites at: Sudbury, Val Caron, Chelmsford and Walden. Home base TBD, but regular visits to the other sites are required.

Are you a compassionate and resourceful Social Worker looking to make a meaningful impact in primary care?

Join the City of Lakes Family Health Team, where you’ll be part of a dynamic interprofessional team dedicated to collaboration, innovation, and delivering exceptional patient-centered care.

Why Join Us?
CoLFHT delivers comprehensive, team-based primary care designed to support our patients. As a Social Worker / Patient Navigator, you’ll play a vital role in helping individuals and families navigate complex systems, access essential resources, and build the skills they need to thrive.

This is a unique opportunity to lead impactful programs, advocate for vulnerable populations, and contribute to the health and well-being of our community. If you're passionate about equity, mental health, and system navigation, we’d love to hear from you.

Responsibilities:
Social Workers are a key part of the patient care circle and should be comfortable working to their full scope of practice. As a Social Worker with our team, in collaboration with the primary care provider and an interprofessional care team, you will:

Mental Health & Psychosocial Support
Provide brief assessments and therapeutic interventions
Proficient in assessment, psychotherapy and psychological counseling techniques for working with individuals, couples, families and communities
Support patients through counseling, education, and outreach
Demonstrated ability to form and maintain helping relationships with patients. • Working knowledge of the Mental Health Act, Healthcare Consent Act, Substitute Decisions Act and community mental health resources;
Collaborate with patients to set goals and monitor progress
Conduct home visits and community outreach
Identify and report cases of child abuse or neglect
Participate in case reviews and team discussions
Educate patients, families, and staff on psychosocial health and prevention strategies
Maintain clear, confidential documentation
Stay current with best practices and share knowledge with the team
Create and support pathways that facilitate the social worker working to their full scope of practice
Ability to work effectively as part of an interdisciplinary team
Patient Navigation & Advocacy
Lead the development of our Patient Navigator program
Help patients access community and social services
Build and maintain a resource database
Advocate on behalf of patients with external agencies
Strengthen communication between community partners and our care team
Assist patients with accessing financial supports, housing, legal aid, and social services
Facilitate self-help sessions on banking, taxes, and navigating forms
Assist patients if required in filling out any forms or applications to support patient navigation or related to the social determinants of health
Build capacity among providers to identify and support patient navigation
Support in the creation and implementation of a social prescribing program
Program Development & Evaluation
Develop tools and guidelines to support best practices
Collaborate with our Quality Improvement team to measure impact
Enhance EMR functionality to support navigation and tracking
Participate in data collection and program evaluation
 

What We Offer
A supportive, inclusive, and forward-thinking work environment
A collaborative team culture that fosters learning, innovation and a shared purpose
Opportunities for professional growth, leadership, and continuing education
A chance to make a lasting impact in the Greater Sudbury community
 

Qualifications
Bachelor’s degree in Social Work from an accredited institution
Minimum 3 years of relevant experience
Registered and in good standing with the Ontario College of Social Workers and Social Service Workers
Experienced in social work interventions and strategies to assist clients or families to achieve optimum psychosocial and social functioning
Working knowledge of the Mental Health Act, Healthcare Consent Act, Substitute Decisions Act and community mental health resources
Experience in providing one-on-one supports to individuals with diversity in income, education, ability, and mental health status
Excellent verbal and written communication. Listening, organizational, multi-tasking and problem-solving skills.
Demonstrated commitment to and knowledge of community-based resources
Demonstrable knowledge of financial matters affecting low-income people, including income security programs and policies, tax systems, access to financial services, and other income support programs such as WSIB and private insurance companies.
Previous experience brokering social support services between agencies
Experience in the development of educational materials for health providers and patients
Experience with data collection, research and quality improvement
Experience with a electronic medical records system is an asset
Demonstrated ability to work effectively in a multi-disciplinary team environment
Bilingual in French and English considered an asset


We are an equal opportunity employer and we celebrate diversity and are committed to creating an inclusive environment for all employees!