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 Assistant2-3 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…