Guide NaviGuide Service Coordinator

Community:
Ravines Edge Service Coordinator Responsibilities

• Assists and educates clients or residents and families to acquire and utilize community services necessary to maintain a self‑reliant lifestyle.
• Acts as a liaison between community agencies, service providers, and clients or residents; seeks out new services, identifies low‑cost providers, and/or negotiates discounts.
• Monitors the delivery of services to clients or residents to ensure services are appropriate, timely, and satisfactory.
• Maintains a resource directory of available community services.
• Maintains professional relationships with all clients or residents in the housing community to identify areas of need and make referrals to community agencies as necessary.
• Maintains resident files, including but not limited to intake information, assessments, service referrals, termination information, quarterly reviews and follow‑up, documentation of human or civil rights violations, and resident/family/provider meeting or communication notes.
• Conducts quarterly Quality Service reviews and follow‑up.
• Submits all required reporting data within specified time frames.
• Networks with service providers to maintain necessary relationships and pursue additional service opportunities through private, local, state, and federal sources.
• May require travel for conferences, training, and other company events.
• Performs all other duties as assigned or directed.
• Promotes wellness activities for all residents, including arranging onsite or mobile healthcare services and screenings; encourages residents to proactively address social, psychological, and physical needs.
• Coordinates educational events for residents, families, and staff regarding community resources (healthcare, home‑ and community‑based supports, benefits programs, life skills programs), including referral processes and eligibility requirements.
• Assists residents in building informal support networks with other residents, family members, and friends.
• Coordinates volunteer support programs with community service organizations.
• Assesses client needs to establish an individualized service plan.
• Acts as a family support system and provides community resources for caregivers as needed.
• Maintains client, family, and provider meeting and communication notes.
• Conducts home visits, including during inclement weather.
• Ability to commute daily for client home visits; requires daily travel to client homes, community service providers, and attendance at trainings, conferences, and company events.
• Completes all required GUIDE assessments, including FAST, ZBI‑22, PROMIS‑10, HRSN, and comprehensive assessments.
• Creates and updates person‑centered service plans to reflect changing client needs.
• Serves as a liaison between clients, caregivers, primary care physicians (PCPs), the GUIDE interdisciplinary team, community agencies, and service providers; seeks out new services to meet client needs.
• Maintains and updates resident files within the electronic medical record, including intake information, assessments, service plans, referrals, progress notes, and meeting/communication documentation.

• Education:
  
  Bachelor’s degree in social work – preferred. GUIDE Navi Guide:
  Associate degree in Nursing, Social Work, or Gerontology – preferred.
• Experience:
  
  Two (2) or more years of experience in social service delivery to the elderly population. Working knowledge of community resources within the geographic service area. GUIDE Navi Guide:
  Experience working with individuals living with Alzheimer’s disease, dementia, or in gerontology – preferred.
• Computer
  
  Skills:
  
  Must be able to proficiently operate a computer, the Internet, Microsoft Office, other relevant software, and basic office equipment.
• Certifications &…