Health Related Social Coordinator - AD

Title: Health Related Social Needs Coordinator - AD278

Location: River House - 211 SE Caruthers Portland, OR 97214

Schedule: This is an in person position, Monday through Friday, 8:00am - 5:00pm.

Wage Range: $24.00 - $29.00 hourly, Non-Exempt

If you are a motivated and dedicated Health Related Social Needs Coordinator looking for an opportunity to contribute to an organization making a positive impact, we want to hear from you!

The mission of NARA NW is to provide education, physical, mental health services, and substance abuse treatment that is culturally appropriate to American Indians, Alaska Natives, and anyone in need.

At NARA NW, we deliver services and support to Native American and Alaska Native communities, helping individuals lead healthier, more fulfilling lives. With over 450 employees across a variety of programs—including medical and dental care, addiction treatment, housing assistance, and enrichment initiatives NARA NW offers numerous opportunities for growth and advancement, all while making a tangible, positive impact on the lives of others.

The Health-Related Social Needs (HRSN) Coordinator addresses a range of social determinants of health, with a primary focus on housing instability and homelessness as critical drivers of health outcomes. This role supports individuals in accessing HRSN benefits through screening, coordination, and ongoing support. The Coordinator is responsible for managing closed-loop referrals, as well as completing invoicing and maintaining accurate documentation related to ongoing HRSN benefits and services.

The role works collaboratively with the social services team, housing providers, and community-based organizations to promote housing stability, improve health outcomes, and reduce health disparities.

• Identify individuals eligible for HRSN benefits and services.
• Develop individualized housing support plans in collaboration with participants, care teams, and housing partners.
• Coordinate referrals to housing providers, supportive programs, and community-based organizations using Unite Us and other closed loop referral software.
• Provide housing navigation and tenancy support services, including assistance with housing applications, move-in readiness, and tenancy stabilization.
• Conduct ongoing follow-up to support housing stability and continuity of care.
• Track housing-related referrals, services, and outcomes in Unite Us, electronic health records, and other required data systems.
• Complete invoicing and documentation for housing-related HRSN services in accordance with program, payer, and grant requirements.
• Serve as a liaison between care coordination teams, housing agencies, and community partners.
• Educate participants on housing resources, program expectations, and participant responsibilities.
• Maintain accurate, timely, and compliant documentation.
• Participate in interdisciplinary team meetings, case reviews, and housing-focused case conferences.
• Stay current on available HRSN benefits, housing resources, and best practices related to housing stability.
• Maintain high level knowledge of all internal NARA NW programs, qualifications, and intake processes.
• Works collaboratively, and maintains professional boundaries with clients, other NARA staff, team members, and treats everyone with respect and dignity at all times.

• Maintain working knowledge of and provide referrals to community services and resources, including Aging and Disability Services, Housing Assistance, Transportation, Food/Shelter Services, and Public Health resources.
• Provide culturally informed support to staff working directly with clients to ensure culturally responsive service delivery.
• Performs other duties as assigned.