Specialist, Care Coordination

NOTE: this role is budgeted to start in the $27-29/hr. range, depending upon experience.

Homage Senior Services, formerly Senior Services of Snohomish County is the largest and most comprehensive nonprofit service provider for older adults, people with disabilities, and their families in Snohomish County. Our guiding principles of independence, dignity, and quality of life are realized through our interconnected core service areas: nutrition, transportation, home repair, and social services. We are committed to building an inclusive workplace and offer you the opportunity to work to your fullest potential while making a difference in the community.

Summary:

The Care Coordination Specialist fosters interdisciplinary collaboration across the care continuum, empowering clients to develop self-management skills and enhance their independence. This role provides case management and social services to clients with complex needs through tailored interventions, including resource referrals, facility visits, home visits, and follow-up calls. The goal is to bridge gaps in care, support goal achievement, and promote long-term stability.

Essential Duties and Responsibilities:

The Care Coordination Specialist, operating within a community health-based program, performs the following:

• Intensive Case Management: Provides individualized, high-touch support to clients requiring complex care interventions, addressing medical, social, and emotional needs holistically. Engages in consistent and thorough follow-ups to assess progress, remove barriers, and ensures continuity of care. Facilitates access to comprehensive resources, including housing stability, medical care, and mental health services, tailoring solutions to each client's circumstances. Develops and monitors individualized care plans, adjusting as needed to address evolving client needs.

• Client Support and Planning: Conducts comprehensive goal-setting sessions, documents risk and needs assessments and collaborates with clients to create and refine actionable care plans over a 90-day period. Educates clients and caregivers on setting realistic goals, accessing resources, and utilizing referrals to promote stability.

• Interdisciplinary Collaboration: Collaborates with fire district personnel, hospital discharge planners, physicians, and ancillary providers to optimize the continuum of care. Acts as a liaison between professional care teams (e.g., hospital staff) and clients/families to ensure seamless transitions and coordinated care efforts.

• Follow-Up and Progress Monitoring: Conducts regular check-ins via telephone and in-person visits to evaluate progress, provide encouragement, and revise care plans as needed. Ensures compliance with treatment plans while empowering clients with self-management skills.

• Documentation and Reporting: Maintains accurate, timely documentation in designated electronic health systems, such as Julota database.

• Professional Development and Teamwork: Participates in ongoing training, seminars, and team meetings to stay current on best practices and enhance service delivery. Demonstrates the ability to work independently with minimal supervision while collaborating effectively in a team environment.

• Additional Responsibilities: Performs other duties as assigned to support program goals and organizational objectives.

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Minimum Qualifications:

• Bachelor's Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral Sciences; or licensure in Counseling, Chemical Dependency, Nursing, or as a Physician's Assistant
• 2-3 years of experience in case management and care coordination
• Proficiency in electronic health platforms
• Demonstrated ability to work independently while effectively coordinating with staff, clients, and community partners
• Strong organizational and prioritization skills to thrive in a fast-paced environment
• Knowledge and application of Trauma-Informed Care practices
• Effective critical thinking and problem-solving abilities
• Strong verbal and written communication skills
• Familiarity with healthcare delivery systems and community resources
• Willingness to work in varied client environments, including those with strong odors, pets, or cigarette smoke
• Proficiency in Microsoft Office Suite (Outlook, Teams, Excel, Word, PowerPoint) and internet navigation
• Valid WA State driver's license and current automobile insurance

Absent any regulatory or contractual requirement for specific education/certification, other combinations of applicable education, training, and experience which provide the knowledge, skills, and abilities necessary to perform effectively in the position may be considered.

Preferred Qualifications:

• Master's Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral Sciences
• Experience working with elder and disabled populations
• Experience engaging with diverse communities
• Fluency in languages other than English

Work Environment and Physical Demands

• Work is performed in an office setting or in client homes, with responsibilities involving both seated and standing activities
• Occasional lifting of up to twenty-five pounds may be required for equipment or supplies
• Travel within the community during normal business hours is a regular part of this role

Please note that this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

SUMMARY OF BENEFITS

Employees working 25 hours or more are eligible to enroll in medical, dental, vision, basic life, and critical illness insurance, with an increased cost share for employees scheduled for 25-29 hours/week. Employees working 20 hours or more per week receive 11 designated paid holidays plus 2 "floating holidays" per year, as well as paid vacation and sick time. Employees age 21 and older are able to enroll in our 401K plan upon hire and, after one year and at least 1000 hours worked, will be eligible for our matching program.

This role is budgeted to start in the $27-29/hr. range, depending upon experience.

Salary : $24 - $38