HRSN Case Manager

About Neighborhood House

Neighborhood House is a non-profit agency providing social services for children, families, seniors, and people experiencing food and housing insecurity. We have been engaging in anti-poverty work for 120 years, offering a safety net to ensure that our community has the support they need to thrive. 

Position Summary

The HRSN Community Based Case Manager works in direct service, responsible for delivering high-quality Health-Related Social Needs (HRSN) care coordination, including Outreach & Engagement (O&E) and Tenancy Supports. This role is essential in advancing Neighborhood House’s whole-person care approach, ensuring that clients receive timely, culturally responsive, and compliant support. 

This is a temporary position through Nov 2027 with potential extension contingent upon funding.

Responsibilities are generally categorized as follows: 

Direct Service & Care Coordination

• Work with HRSN referrals to assess eligibility for the OHP HRSN Medicaid benefit and work with eligible clients to provide both short and long-term support.
• Provide Outreach and Engagement services, including screening for needs, creating short action plans, and connecting members to resources.
• Hold a case load of 18-20 clients (part-time) / 28-30 clients (full time).
• Provide Tenancy Support and Procurement services once housing supports are authorized.
• Develop and update individualized care plans, incorporating client voice, goals, and priorities.
• Deliver trauma-informed, culturally responsive services with a strong equity lens.
• Maintain accurate, timely documentation of all client contacts in the client management system.
• Support clients with applications for HRSN services, benefits, or other resources.
• Coordinate warm handoffs with internal NH programs (Food Security, Education, Senior Services) and external partners.

Requirements:

• Minimum 3 years of experience in community health work, social work, case management, client advocacy, or social services. 
• Proficiency in data entry, documentation, and maintaining organized records.
• Strong understanding of social determinants of health and barriers to accessing services.
• Experience in outreach, referral navigation, or connecting clients to health and social services.
• Experience working with unhoused individuals as well as vulnerable and disadvantaged populations.
• Associate’s degree in social work or related field, or equivalent experience. 
• Strong interpersonal and communication skills to effectively engage with diverse clients, staff, and stakeholders.
• Demonstrated ability to work effectively with diverse populations, including immigrant and refugee families, and people from various cultural backgrounds.
• Ability to apply trauma-informed and culturally responsive approaches in client interactions.
• Capacity to serve as a peer trainer/coach, helping others adopt new systems and workflows.
• Ability to work independently while collaborating with a multidisciplinary team.
• Knowledge of health and social service systems, including Medicaid and community-based resources.
• Adaptability and flexibility to support ongoing program development and process improvements.
• Proficiency in Microsoft Office (Word, Excel), Outlook, Teams, and comfort learning and using client data/documentation systems.
• Ability to handle confidential and sensitive information with discretion and professionalism.
• Strong organizational and time management skills, with the ability to manage multiple tasks and deadlines.

Preferred Qualifications:

• Experience working with or within a community-based organization.
• Familiarity with Medicaid, the Oregon Health Plan, or HRSN services.
• Knowledge of documentation systems and program evaluation.
• Bachelor's degree in social work or related field.

Benefits

Neighborhood House offers full-time employees a comprehensive benefits package, including:  

• Generous PTO and 12 paid holidays
• Affordable health insurance with 95% of the cost paid by NH
• 403b retirement plan
• Company-paid life insurance. Voluntary life, long-term disability, accident, and critical illness insurance.
• Flexible Spending Account (FSA)
• Employee Assistance Program (EAP) with free counseling