BHBH Care Coordinator

Title: BHBH Care Coordinator

Department/Division: Social Services

Status: Full-Time / Monday – Friday, 8:00 AM – 4:30 PM (evenings and weekends as needed)

Salary: Hourly/ DOE

Supervisor: BHBH Program Manager, Social Services Director

Subordinates: None

The BHBH Care Coordinator provides intensive case management and housing‑focused care coordination for individuals and families currently experiencing or at high risk of homelessness. The coordinator plays a key role in connecting clients to stable housing, supportive services, and long‑term wellness through a culturally responsive, trauma‑informed approach.

The position is embedded within a tribal wraparound team and collaborates with Indian Health Services, Behavioral Health, Courts, Parole/Probation, Child Welfare, and other tribal and community‑based agencies to promote housing stability, self‑sufficiency, and access to essential services.

• Maintain a caseload of 12–15 clients, ensuring at least 14 hours of monthly service contact per client, including weekly face‑to‑face visits.
• Conduct thorough intakes within two (2) weeks of referral, identify immediate needs, and begin developing an individualized care plan.
• Within 30 days, complete a Plan of Care (POC) and 24‑hour Crisis Plan based on client strengths, cultural values, and housing needs.
• Collaborate with housing providers, landlords, and agencies to secure and maintain permanent housing placements.
• Assist clients in completing housing applications, gathering documentation, and navigating housing authority or tribal housing processes.
• Provide tenancy support services, including budgeting, life skills, communication with landlords, and eviction prevention strategies.
• Coordinate transportation for appointments and emergency services as needed.
• Facilitate access to supportive services, including mental health, substance use treatment, benefits enrollment, and vocational programs.
• Monitor service delivery and act as liaison between the client, family, and team to ensure quality and consistency.
• Maintain up‑to‑date, strength‑based client records and complete all documentation in a timely manner.
• Attend and participate in tribal and county housing case conferencing, team meetings, and interagency collaborations.
• Conduct home visits and field‑based outreach to support client engagement and housing retention.
• Identify and advocate for culturally responsive resources that reflect the needs of Native families and individuals.
• Assist with community education and outreach related to housing stability and homelessness prevention.
• Support the development and implementation of housing‑related programs and policies within the Tribe.
• Participate in required training, staff development, and reflective supervision.
• Other duties as assigned.

• Analyze complex problems and develop culturally appropriate, solution‑focused plans.
• Manage detailed records, data collection, and client communications effectively.
• Interpret housing regulations and funding requirements to support client eligibility and program compliance.
• Provide input into program design and continuous improvement based on client outcomes.

• Knowledge of housing‑first and trauma‑informed care models, especially in serving individuals and families experiencing or at risk of homelessness.
• Familiarity with local housing systems, public benefits, and supportive services.
• Strong interpersonal and communication skills to engage with clients, community partners, and landlords.
• Ability to work independently with strong follow‑through, while contributing to a collaborative team environment.
• Ability to maintain accurate documentation, case notes, and timely reporting.
• Cultural sensitivity and respect for Native communities; support for tribal values and philosophies.
• Basic computer skills for data entry, communication, and use of case management systems.
• Must maintain confidentiality and follow ethical guidelines at all times.
• Previous experience working with Native American communities or vulnerable populations preferred.

• Bachelor’s or…