Complex Care Specialist

The Heartland HOUSED Complex Care Specialist will play a critical role in supporting and enhancing healthcare and housing integration efforts throughout Sangamon County. The Complex Care Specialist is responsible for engaging with individuals experiencing homelessness who frequently utilize hospital emergency rooms for care, building trusting relationships, and connecting individuals to stable housing and additional services including primary healthcare, mental health care, and substance use treatment.

Using a housing-focused and trauma-informed approach, the Specialist will prioritize assisting individuals in obtaining stable housing while addressing complex medical, behavioral, and social barriers to care. Complex Care Specialists will also provide intensive case management and ongoing tenancy support to ensure long-term stability and reduce reliance on emergency medical systems. This position is Full-Time and reports to the Heartland HOUSED Executive Director while working closely with Heartland HOUSED Street Outreach Coordinator, hospital discharge planners, emergency roomstaff, and community health partners.

Schedule will include 37.5 hours per week with some flexibility required to respond to hospital-based crises or client needs.

The Complex Care Specialist will be funded through a Frequent User System Engagement Pilot in partnership with HSHS St. John’s Hospital and Springfield Memorial Hospital. The pilot program is funded through 2028.

• Conduct regular outreach and engagement with individuals experiencing homelessness who are identified as frequent users of hospital emergency departments.
• Establish trust and rapport through consistent, respectful, and non-judgmental interactions in hospital settings, shelters, and community encampments.
• Provide intensive housing case management, including assisting individuals in obtaining required documentation (e.g., IDs, income verification) and navigating programs to support ongoing housing stability.
• Deliver ongoing tenancy support and independent living skills training post-housing to support stability efforts and prevent eviction.
• Coordinate warm handoffs to primary healthcare providers to establish a consistent medical home and reduce non-emergent ER utilization.
• Facilitate direct connections, schedule appointments, and accompany clients to specialized care, including psychiatric services, medical specialists, and substance use disorder treatment.
• Respond to Complex Care and ER diversion referrals from hospital staff, Heartland HOUSED team members, and community partners.
• Troubleshoot complex medical and social cases through multidisciplinary case conferencing to ensure continuity of care.
• Ensure Coordinated Entry access for eligible individuals experiencing unsheltered or chronic homelessness.
• Maintain accurate and timely documentation of activities, interventions, and health/housing outcomes in accordance with program guidelines.
• Regularly enter and maintain accurate participant data in the HCoC Homeless Management Information System (HMIS) and related care tracking platforms.
• Other duties as assigned.

• A high school diploma or GED required; a Bachelor’s degree in Social Work, Psychology, Public Health, or a related field is a plus. Experience working in similar positions will be considered.
• Lived experience of homelessness, healthcare navigation experience, Peer Support training, or Community Health Worker (CHW) certification are plusses.
• Experience working directly with vulnerable populations, especially those experiencing chronic homelessness, severe mental illness, or substance use disorders is preferred.
• Must have a valid driver’s license and reliable transportation.
• Str…