Tribal Wraparound Care Coordinator

JOB TITLE:
Tribal Wraparound Care Coordinator
STATUS:
Full-time, Permanent
FLSA:
Exempt
REPORTS TO:
Program Manager / Director
SUPERVISES: N/A

WORKING HOURS:
The Tribal Wrap Around Care Coordinator is an exempt position that provides care coordination case management services
to adults and/or youth who are in need of housing resources often due to unmet social, health, behavioral health needs and
may have criminogenic needs. This position has regular business hours but often requires work in early mornings,
evenings, and weekends. May be required to perform after-hours standby services as needed or some evening work,
especially during the winter shelter season.

SUMMARY:
The Tribal Wrap Around Care Coordinator is responsible for providing intensive care coordination for individuals, families, and
youth who have been identified as being high risk for homelessness or is currently homeless. The care coordination will
identify system partners such as Indian Health Services, Behavioral Health, Probation / Parole, Courts, Elder & Disability
Services, Veteran Services, and Child Welfare to bring them together as tribal wraparound team to help empower the client
toward self-sufficiency and independence. The position assists and aids individuals and families requiring assistance from
the Tribe. The position fills a central role in linking homeless individuals and families to an appropriate housing plan of care
and supporting them in tenancy sustaining services. The goal is to facilitate rapid and resourced exits from homelessness
into permanent supportive housing and provides participant advocacy, case management, benefit establishment, linkage to
Mental Health and/or Substance Use Services, linkage to stable housing and all other supportive services as needed.
This position is funded in full or in-part through Homeless Housing, Assistance and Prevention (HHAP), Housing and Disability
Advocacy Program (HDAP), Bringing Families Home (BFH), Behavioral Health Bridge Housing (BHBH), Home Safe, Native
American Housing Assistance and Self Determination Act (NAHSDA). The worker will be assigned a focus population but
cross-trained in all areas and expected to assist with other focus populations based on company and community need.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Maintains a caseload of 12-15 with a minimum of 14 hours of service contact per month per client to include weekly
face-to-face contacts with the client while promoting tribal wraparound philosophy and practices.
2. Assemble a Tribal Wrap Around Team within two (2) weeks of referral by interviewing the client, identifying family
members/natural supports/agency representatives and other significant persons. Uncover the client's strengths and
needs, provides assistance with any immediate needs, as well as completes the initial Crisis Plan.
3. Within the first 30 days, coordinates the meeting of the Team and develops the initial individualized Plan of Care (POC)
based on the identified strengths and needs, including a comprehensive 24-hour Crisis Plan. The Plan should reflect the
best possible fit with the culture, values and beliefs of the client.
4. Monitor the provision and quality of services provided to the client and family through the Team and is the liaison when
new services/resources need to be sought or developed.
5. Provides or arranges for transportation for his/her clients to appointments, crisis/emergency services, etc., if needed.
6. Provides or secures support and crisis/emergency services for the client.

Dry Creek Rancheria

Job Description s, Policies & Procedures
7. Completes all the necessary paperwork in a strength-based manner and maintains accurate information on-line,
ensuring that demographic information is up-to-date, as well.
8. Collaborates with other system partners such as Indian Health Services, Behavioral Health, Probation / Parole, Courts,
Elder & Disability Services, Veteran Services, and Child Welfare to bring them together as tribal wraparound team to
help empower the client toward self-sufficiency and independence.
9. Shall dress in a respectful manner and maintain a respectful demeanor and presentation at all times.
10. Provide written and verbal…