Integrated Team Care Program


The ITC Care Coordinator is part of the Chronic Disease Team of Mawarnkarra Health Service.  The Service’s objective is to provide holistic, primary health care services to the Aboriginal people of the West Pilbara region.


Roebourne with travel within the Pilbara.


Indigenous Health Project Officer


37.5 hours per week Monday to Friday 8:30am to 4:45pm with 45minutes (unpaid) for lunch daily. You are to be ready for work no later than 8:30am daily. 

Other conditions of employment are identified in your contract for employment.

All Mawarnkarra employees are required to comply with all policies in force at the time of commencement of employment and those implemented from time to time.

As part of the orientation program, employees are required to sign declarations and agreement pursuant to policies of the Health Service.


The role of the care coordinator involves but is not limited to; working collaboratively with patients, general practices, AMSs, and other service providers to assist with the care coordination of eligible patients with chronic disease. A care coordinator provides support to identify when a patient’s condition may require further assistance from a health professional, with relation to their GP care plan. This role has an objective of assisting Aboriginal and Torres Strait Islander (ATSI) people in the Pilbara, not just Mawarnkarra Health Service patients.  The role will include clinical care as necessary.

The care coordinator works with the IHPO to ensure compliance of funding requirements and reporting obligations.

The Care Coordinator provides guidance and support to the Outreach Worker to provide exceptional care coordination to the selected patients enrolled in the ITC program.


  • Must have current registration as Aboriginal Health Practitioner/Enrolled or Registered Nurse.
  • Ability to assist & support Aboriginal and Torres Strait Islander people to understand their chronic health condition and how to manage it.
  • Good interpersonal and communication skills (written and verbal). Requires excellent communication skills with Aboriginal and Torres Strait Island patients.
  • Ability to manage the administrative component of the role, not limited to and entering data and developing performance reports.
  • Comprehensive understanding of culturally appropriate health care, or willingness to learn.
  • A demonstrated capacity to improve skills in working effectively, positively and collaboratively within a multi-disciplinary team.
  • Passion and drive to work independently and in a team environment.
  • Ability to prioritise workload and demonstrated organisational skills.
  • Commitment to ongoing participation in education, professional development, evidence-based research and quality assurance.


  1. Care Coordination
  • Assisting patients who have a care plan by a GP in a general practice or an AMS with managing the activities and services needed to improve their health outcomes. Assistance may be via face-to-face, telephone, or other electronic means.
  • Assisting patients to:
    • Adhere to treatment regimens – for example, encouraging medication compliance;
    • Develop chronic condition self-management skills; and
    • Improve their capacity to engage with the broader health system and connect with appropriate community-based services.
  • Undertaking care coordination activities in accordance with the patient’s GP care plan. Care coordination activities may include, but are not limited to:
    • Arranging the required services outlined in the patient’s care plan;
    • Ensuring there are arrangements in place for the patient to get to appointments;
    • Involving the patient’s family or carer as appropriate;
    • Transferring and updating the patient’s medical records;
    • Assisting the patient to participate in regular reviews by their primary care providers; and
    • Providing appropriate clinical care.
  • Travel within the Pilbara to assist patients and coordinate activities with the primary health provider and health services.


  • Assisting eligible patients to access the ITC Supplementary Services Funding Pool, providing access to specialist, allied health and other support services in line with their care plan, and specified medical aids they need to manage their condition effectively.
  • Liaising with mainstream health providers, educating them on culturally appropriate care.
  • Working collaboratively with other members of the Pilbara Integrated Team Care program.
  1. Administrative duties
  • Ensure all care provided to a patient is entered into the MHS data management system.
  • Ensure all data is accurate and up-to-date.
  • Provide quarterly reports to the IHPO to be used for reporting to WAPHA
  1. Quality improvement activities
  • Participate in continual quality improvement in the delivery of patient services.
  • Ensure all standards are maintained consistent with evidence based best practice standards.
  1. Perform other duties as required by management.


  1. Professional responsibilities
  • Work in collaboration with Chronic Disease Nurses, Indigenous Health Program Officer (IHPO), and Outreach Workers on relevant issues.
  • Maintain the highest standards of professional conduct.
  • Participate in and contribute to the successful outcomes of the organisation.
  • Participate in maintaining a safe working environment.
  • Undertake travel as required to perform the duties of this role.


Attend and participate in the professional development programs and relevant external seminars and conferences, as approved.


Performance will be appraised on an on-going basis and formally at the first 3 months and annually thereafter.

Consent to undergo a Working with Children Check and a National Police Certificate.  Employment is conditional pending the outcome of these checks.

Current Drivers Licence

Current CPR Certificate

COVID-19 Vaccinated. (triple vax as per government mandate for all health care workers)

All employees are required to adhere to Smoking policy and be willing to undertake a random drug and alcohol screening.

Please email your resume and application for a role through to HR Department You will receive confirmation that your application has been received. Should we progress your application to interview, we will contact you to arrange.


MHS may commence appointment proceedings immediately, appoint by invitation or make no appointment at all. This opportunity is only open to candidates with the right to work in Australia. Aboriginal and Torres Strait Islander people are encouraged to apply.

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