Integrated Care Specialist - Shelter

Job Description

Description:

POSITION TITLE: Integrated Care Specialist – Shelter Based

REPORTS TO: Team Lead

FLSA CLASSIFICATION: Non-Exempt

POSITIONS SUPERVISED: None

POSITION OVERVIEW:

The Integrated Care Specialist – Shelter Based provides case management and integrated care services within a shelter-based environment, supporting residents in achieving stability, improving functioning, and securing permanent housing. This role utilizes a Housing First, trauma-informed, and harm reduction approach to deliver person-centered services, coordinate care, and support residents in reaching individualized housing, health, and wellness goals.

ESSENTIAL FUNCTIONS

Service Delivery

• Provide direct case management services to residents in a shelter-based environment, supporting progress toward housing stability, recovery, and independence
• Develop and maintain individualized service/treatment plans, including goal setting, strengths assessment, and ongoing updates
• Coach and support residents in developing independent living and ADL skills , medication management and self-care, budgeting and financial stability
• Assist in securing and maintaining housing, including housing searches and landlord engagement
• Support access to benefits and resources (e.g., SSI/SSDI, food assistance, healthcare); transport residents as needed using a personal vehicle

Care Coordination & Collaboration

• Coordinate services across internal teams, providers, and partners to support continuity of care
• Advocate on behalf of residents to ensure access to needed services and resources
• Communicate with treatment team members, stakeholders, and community agencies
• Participate in team meetings, case reviews, and communication to align service delivery

Monitoring Progress & Responding to Client Needs

• Monitor resident progress, engagement, and stability within the shelter-based environment
• Identify changes in needs, risks, or barriers to housing and adjust service accordingly
• Provide crisis intervention, conflict resolution, and support for behavioral health needs
• Develop and support crisis planning (e.g., WRAP plans) and respond to urgent situations

Client Engagement & Support

• Build strong, professional relationships using a person-centered, trauma-informed approach
• Engage residents in services that promote dignity, choice, and empowerment
• Encourage participation in goal planning, services, and community integration
• Promote a welcoming, respectful shelter-based environment that enhances the overall experience

Documentation & Compliance

• Complete accurate, timely documentation, including service notes, treatment plans, and required reports , ensuring agency, regulatory, and contract standards, and productivity expectations
• Maintain communication logs and required records to support continuity of care
• Complete required trainings and adhere to all policies, procedures, and safety standards
• Other duties as assigned

ORGANIZATION STANDARDS:

Professionalism and Communication

Demonstrates clear, respectful, and professional communication in both verbal and written interactions, with a focus on collaboration and solution-oriented dialogue. Shares information responsibly and addresses concerns constructively while maintaining a positive, professional demeanor—even in challenging situations.

Time & Priority Management

Effectively manages workload by prioritizing tasks, planning proactively, and addressing challenges to meet deadlines and responsibilities. Maintains a solution-focused approach and professional composure while balancing competing priorities.

Reliability & Accountability & Ownership

Demonstrates dependability by consistently meeting commitments, deadlines, and responsibilities while taking ownership of work and outcomes. Acts with integrity, follows…