The primary role of the Care Coordinator is to provide comprehensive strengths-based, trauma informed, case management services to homeless and recently housed adults.

The Care Coordinator uses harm reduction techniques to engage with individuals who are adults and have a history of experiencing homelessness and mental health illness and / or a co-occurring substance use disorder or other medical impairments.

The Care Coordinator works collaboratively with the Contra Costa Employment and Human Services Department (EHSD), Contra Costa Health Plan, Healthcare for the Homeless, County Behavioral Health services, County Health Services, Coordinated Entry systems, and other community-based programs to retain housing, engage in services, and stabilize chronically homeless individuals.

Salary Range : $30.00 - $34.62

ESSENTIAL FUNCTIONS

• Support and build trust with participants in transitioning from the streets to permanent housing placement
• Responsible for the comprehensive assessments that are inclusive of medical needs, psychosocial assessment, safety assessment, substance use disorder assessment, housing needs, and all other relevant areas of concern
• Develops an individualized service plan in coordination with Contra Costa continuum of care as well as leverages relevant community resources as needed
• Provide short-term, clinical case management services with the goal of linking individuals served to a healthy home and stable housing
• Administer intake questionnaires, assessments and other forms of tracking documentation as needed; track data for reporting, maintain case notes, and appropriate records and files
• Utilize motivational interviewing techniques to explore participants’ motivation towards behavioral change
• Provide direct crisis counseling and problem identification. Accompany participants to appointments and other services
• Support participants as they navigate the criminal justice and court systems. Advocate for participants by interacting with judges, court mental health staff, public defenders,
• Identify if individuals are connected to relevant services; if not, collaborate with community partners such as : clinics, public health, public assistance, psychiatry, mental health, etc.

to ensure individuals are connected to eligible services

• Assist individuals with completing applications for services, transporting them to services, and other appointments as needed
• Provide a warm hand-off when individuals are connected to long-term services and providers
• Maintain and interact in a culturally sensitive, respectful, and professional demeanor.
• Attend and participate in weekly case conferences as part of the county-wide CORE outreach program.
• Attend community meetings with other service providers to share program information and coordinate services.
• Comply with all policies and procedures guiding the work of this position and the department overall.
• Attend training and meetings as required.
• Travel between various locations
• All other duties as assigned.

Care Coordinator (CalAIM)

o See Essential Functions.

Housing Transition Navigator

The assessment may include collecting information on the member’s housing needs, potential housing transition barriers, and identification of housing retention barriers.

• Develop an individualized housing support plan based upon the housing assessment that addresses identified barriers, includes short- and long-term measurable goals for each issue, establishes the member’s approach to meeting the goal, and identifies when other providers or services, both reimbursed and not reimbursed by Medi-Cal, may be required to meet the goal.
• Search for housing and present options.
• Assist in securing housing, including the completion of housing applications and securing required documentation (e.g.

Social Security card, birth certificate, prior rental history).

Assist with benefits advocacy, including assistance with obtaining identification and documentation for SSI eligibility and supporting the SSI application process.

Such service can be subcontracted out to retain needed specialized skillset.

• Identify and secure available resources to assist with subsidizing rent (such as HUD’s Housing Choice Voucher Program (Section 8), or state and local assistance programs) and matching available rental subsidy resources to Members.
• Identify and secure resources to cover expenses, such as security deposit, moving costs, adaptive aids, environmental modifications, moving costs, and other one-time expenses.
• Assist with requests for reasonable accommodation, if necessary.
• Landlord education and engagement
• Ensure that the living environment is safe and ready for move-in.
• Communicate and advocate on behalf of the Member with landlords.
• Assist in arranging for and supporting the details of the move.
• Establish procedures and contacts to retain housing, including developing a housing support crisis plan that includes prevention and early intervention services when housing is jeopardized.
• Identify, coordinate, and secure non-emergency, non-medical transportation to assist Members’ mobility to ensure reasonable accommodations and access to housing options prior to transition and on move in day.
• Identify, coordinate, and secure environmental modifications to install necessary accommodations for accessibility (see Environmental Accessibility Adaptations Community Support).

Housing Tenancy and Sustaining Services Case Manager

• Provide early identification and intervention for behaviors that may jeopardize housing, such as late rental payment, hoarding, substance use, and other lease violations.
• Provide education and training on the role, rights, and responsibilities of the tenant and landlord.
• Provide coaching on developing and maintaining key relationships with landlords / property managers with a goal of fostering successful tenancy.
• Coordinate with the landlord and case management provider to address identified issues that could impact housing stability.
• Aid in resolving disputes with landlords and / or neighbors to reduce risk of eviction or other adverse action including developing a repayment plan or identifying funding in situations in which the Member owes back rent or payment for damage to the unit.
• Provide advocacy and linkage with community resources to prevent eviction when housing is or may potentially become jeopardized.
• Assist with benefits advocacy, including assistance with obtaining identification and documentation for SSI eligibility and supporting the SSI application process.

Such service can be subcontracted out to retain needed specialized skillset.

• Assist with the annual housing recertification process.
• Coordinating with the tenant to review, update and modify their housing support and crisis plan on a regular basis to reflect current needs and address existing or recurring housing retention barriers.
• Provide continuing assistance with lease compliance, including ongoing support with activities related to household management.
• Health and safety visits, including unit habitability inspections.
• Other prevention and early intervention services identified in the crisis plan that are activated when housing is jeopardized (e.

g., assisting with reasonable accommodation requests that were not initially required upon move-in).

Teaching independent living and life skills including assistance with and training on budgeting, including financial literacy and connection to community resources.

JOB QUALIFICATIONS

• Must have a working knowledge of Psychiatric Disorders as well as knowledge and ability to implement the following evidence-based models : Harm Reduction, Housing First, Strength- based Case Management and Motivational Interviewing.
• Ability to build supportive and respectful working relationships with individuals experiencing homelessness that instills hope and promotes self-determination.
• Understanding and practice of culturally sensitive components of direct service delivery through open dialogs and self-exploration with diverse group.
• Demonstrated ability to work effectively with people of diverse races, ethnicities, nationalities, sexual orientations, gender identities, socio-economic backgrounds, religions, ages, English- speaking abilities, immigration status, and physical abilities in an intersectional environment.
• Demonstrated personal and professional commitment to Cultural Humility, Diversity, Equity, and Inclusion practices and the development and implementation of materials through a lens of social justice.
• Must possess strong engagement skills.
• Proven ability to work independently and as an effective and collaborative member of a team.
• Strong community networking skills and ability to build resources and relationships that improve continuity of care.
• Excellent verbal skills. Strong organizational and time management skills.
• Possess an understanding of and practice cultural sensitivity through open dialogue and self- exploration with diverse groups, while providing direct services.
• Ability to effectively intervene in crisis situations, with de-escalation techniques.
• Professional level competency using Internet, email, and Microsoft Word computer applications.
• Ability to successfully and efficiently complete tasks in an environment where background noise is present, and interruptions may be constant.
• Must be able to access remote locations that may require traveling through rough terrain in excess of two miles in possible inclement weather conditions.

Education / Experience

• Education : Possession Bachelor’s Degree from an accredited college or university in Public Health, Counseling, Social Work, or a closely related field.
• Experience : Minimum 2 years of direct experience working with people with serious mental illness, individuals with a dual diagnosis and / or the homeless population.

Substitution : Education : Will consider candidates who have an Associate’s Degree from an accredited college in Public Health, Counseling, Social Work, or a closely related field OR an Alcohol or Other Drug Certificate from an accredited college.

Experience : 3 years of full-time housing case management, or its equivalent, experience in a social services or mental health program providing services to homeless persons.

Desired Qualifications :

• Bilingual, bicultural in Spanish.
• Lived experience of homelessness and / or accessing behavioral health services.
• Previous experience or training in street outreach and clinical case management.
• Knowledge of Contra Costa County and community resources.
• Knowledge of the Contra Costa emergency provider network.
• Prior experience with documentation and billing procedures.

Certificates / Licenses / Clearances

• CPR and first aid certification within 90 days of hire.
• A valid California driver’s license, proof of vehicle insurance, and reliable transportation will be needed to carry out job-related essential functions as traveling between sites is a requirement and may also need to be able to drive County issued vehicles.
• Drivers must have a clean record with no infraction / accidents and be 21 years of age or older.

PHYSICAL DEMANDS

Stand Frequently

Walk Constantly

Sit Frequently

Handling / Fingering Frequently

Reach Outward Frequently

Reach Above Shoulder Frequently

Climb, Crawl, Kneel, Bend Frequently

Lift / Carry Occasionally - Up to 50 lbs

Push / Pull Occasionally - Up to 50 lbs

See Constantly

Taste / Smell Not Applicable

Not Applicable : Not required for essential functions

Occasionally : (0 - 2 hrs. / day)

Frequently : (2 - 5 hrs. / day)

Constantly : (5 hrs. / day)

EEOC STATEMENT

It is the policy of Heluna Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.

Last updated : 2024-04-29