Community Services Coordinator - Intense Case Management

You will provide individualized, long-term intensive case management to clients. The coordinator assesses eligibility and need, develops client-specific Self‑Sufficiency Plans, coordinates services across multiple systems, completes Quality of Life Score assessments, maintains regular client contact, and documents measurable progress toward safety, stability, functioning, and independence.

• Screen referrals for eligible status, qualifying vulnerability, eligibility window, and demonstrated need for at least six months of intensive case management.
• Verify identity, status, eligibility date, non-duplication, and supporting documentation; complete required notification or approval processes before enrollment.
• Conduct the intake assessment, identify the primary vulnerability, provide comprehensive orientation, explain confidentiality and program responsibilities, and obtain the required Letter of Agreement.
• Develop an individualized Self‑Sufficiency Plan within required timelines using SMART goals, action steps, responsibilities, time frames, referrals, and strategies to remove barriers.
• Complete Quality of Life Score and progress assessments every 180 days and at case closure; use results to revise goals and service intensity.
• Maintain meaningful client communication at least monthly and more often based on risk, need, and the SSP; document all contacts and attempted contacts.
• Coordinate services across housing, food, income, employment, financial management, physical and mental healthcare, transportation, benefits, social adjustment, and family wellness.
• Accompany or prepare clients for appointments when necessary, advocate for access, follow up with providers, and help clients build skills to navigate systems independently.
• Provide culturally and linguistically appropriate support through qualified interpretation and translated documents; protect confidentiality and informed decision‑making.
• Prepare requests for approved emergency financial, transportation, or childcare assistance when needed to address the client’s vulnerability or enable participation in services.
• Identify and respond to safety concerns involving abuse, neglect, domestic or gender‑based violence, trafficking, suicide risk, exploitation, homelessness, or serious health needs through immediate consultation and established procedures.
• Coordinate dual enrollment and maintain ongoing communication with PIR, MG, PC GAPS, RSS, healthcare, legal, mental health, schools, and other providers to prevent duplication.
• Submit database requests and documentation for beyond eligibility, re‑enrollment, transfer, extension, or other required approvals within established timelines.
• Maintain a complete, secure, and monitoring‑ready PC ICM case file with eligibility, agreements, assessments, QLS, SSP, referrals, assistance, case notes, approvals, and closure documents.
• Complete case closure assessment and letter, document closure status, provide ongoing‑resource referrals, and ensure final database entries are accurate.
• Participate in supervision, case consultation, training, quality review, outreach, monitoring preparation, and program improvement.

• At least two years of case management, healthcare navigation, behavioral health support, disability services, or related experience.
• Demonstrated ability to manage complex cases, maintain professional boundaries, and document services accurately.
• Valid driver’s license, reliable transportation, and ability to meet IIW driving and insurance requirements.

• Experience with intensive case management, trauma‑informed services, behavioral health, disability, domestic violence, trafficking, or elder/youth services.
• Training in…