Specialist, Care Coordination

Homage-Senior-Services; Everett (WA); On-site; USD 37,195 - 39,950; Full time

Job summary

Homage Senior Services is seeking a Care Coordination Specialist to provide high-touch case management and social services for clients with complex needs. You will conduct goal-setting sessions, coordinate with hospitals and community partners, and monitor progress through regular follow-ups in home and office settings.

The role emphasizes trauma-informed care, strong communication, and the ability to develop individualized care plans over a 90-day horizon, with duties including documentation

Qualifications

• Bachelor’s Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral Sciences; or relevant licensure.
• 2-3 years of experience in case management and care coordination.
• Proficiency with electronic health platforms and health information systems.
• Strong verbal and written communication skills.
• Knowledge of trauma-informed care practices and healthcare delivery concepts.
• Ability to coordinate with staff, clients, and community partners.

Responsibilities

• Provide intensive case management and high-touch client support.
• Develop and monitor 90-day care plans with risk and needs assessments.
• Collaborate with hospital staff, discharge planners, physicians, and others.
• Conduct regular follow-ups via calls and client visits; adjust plans as needed.
• Document activities in electronic health records and prepare reports.
• Participate in ongoing training and team meetings; work independently when needed.

Skills

Case management

Trauma-Informed Care

Communication skills

Critical thinking

Organizational skills

Education

Bachelor’s Degree in Social Work or related field

Master’s Degree (preferred)

Tools

Electronic health platforms

Microsoft Office Suite

Job description

NOTE: this role is budgeted to start in the $27-29/hr. range, depending upon experience.Homage Senior Services, formerly Senior Services of Snohomish County is the largest and most comprehensive nonprofit service provider for older adults, people with disabilities, and their families in Snohomish County. Our guiding principles of independence, dignity, and quality of life are realized through our interconnected core service areas: nutrition, transportation, home repair, and social services. We are committed to building an inclusive workplace and offer you the opportunity to work to your fullest potential while making a difference in the community.Summary:The Care Coordination Specialist fosters interdisciplinary collaboration across the care continuum, empowering clients to develop self-management skills and enhance their independence. This role provides case management and social services to clients with complex needs through tailored interventions, including resource referrals, facility visits, home visits, and follow-up calls. The goal is to bridge gaps in care, support goal achievement, and promote long-term stability.Essential Duties and Responsibilities:The Care Coordination Specialist, operating within a community health-based program, performs the following:Intensive Case Management: Provides individualized, high-touch support to clients requiring complex care interventions, addressing medical, social, and emotional needs holistically. Engages in consistent and thorough follow-ups to assess progress, remove barriers, and ensures continuity of care. Facilitates access to comprehensive resources, including housing stability, medical care, and mental health services, tailoring solutions to each client’s circumstances. Develops and monitors individualized care plans, adjusting as needed to address evolving client needs.Client Support and Planning: Conducts comprehensive goal-setting sessions, documents risk and needs assessments and collaborates with clients to create and refine actionable care plans over a 90-day period. Educates clients and caregivers on setting realistic goals, accessing resources, and utilizing referrals to promote stability.Interdisciplinary Collaboration: Collaborates with fire district personnel, hospital discharge planners, physicians, and ancillary providers to optimize the continuum of care. Acts as a liaison between professional care teams (e.g., hospital staff) and clients/families to ensure seamless transitions and coordinated care efforts.Follow-Up and Progress Monitoring: Conducts regular check-ins via telephone and in-person visits to evaluate progress, provide encouragement, and revise care plans as needed. Ensures compliance with treatment plans while empowering clients with self-management skills.Documentation and Reporting: Maintains accurate, timely documentation in designated electronic health systems, such as Julota database.Professional Development and Teamwork: Participates in ongoing training, seminars, and team meetings to stay current on best practices and enhance service delivery. Demonstrates the ability to work independently with minimal supervision while collaborating effectively in a team environment.Additional Responsibilities: Performs other duties as assigned to support program goals and organizational objectives.Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.Minimum Qualifications:Bachelor’s Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral Sciences; or licensure in Counseling, Chemical Dependency, Nursing, or as a Physician’s Assistant2-3 years of experience in case management and care coordinationProficiency in electronic health platformsDemonstrated ability to work independently while effectively coordinating with staff, clients, and community partnersStrong organizational and prioritization skills to thrive in a fast-paced environmentKnowledge and application of Trauma-Informed Care practicesEffective critical thinking and problem-solving abilitiesStrong verbal and written communication skillsFamiliarity with healthcare delivery systems and community resourcesWillingness to work in varied client environments, including those with strong odors, pets, or cigarette smokeProficiency in Microsoft Office Suite (Outlook, Teams, Excel, Word, PowerPoint) and internet navigationValid WA State driver’s license and current automobile insuranceAbsent any regulatory or contractual requirement for specific education/certification, other combinations of applicable education, training, and experience which provide the knowledge, skills, and abilities necessary to perform effectively in the position may be considered.Preferred Qualifications:Master’s Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral SciencesExperience working with elder and disabled populationsExperience engaging with diverse communitiesFluency in languages other than EnglishWork Environment and Physical DemandsWork is performed in an office setting or in client homes, with responsibilities involving both seated and standing activitiesOccasional lifting of up to twenty-five pounds may be required for equipment or suppliesTravel within the community during normal business hours is a regular part of this rolePlease note that this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.SUMMARY OF BENEFITSEmployees working 25 hours or more are eligible to enroll in medical, dental, vision, basic life, and critical illness insurance, with an increased cost share for employees scheduled for 25-29 hours/week. Employees working 20 hours or more per week receive 11 designated paid holidays plus 2 "floating holidays" per year, as well as paid vacation and sick time. Employees age 21 and older are able to enroll in our 401K plan upon hire and, after one year and at least 1000 hours worked, will be eligible for our matching program.This role is budgeted to start in the $27-29/hr. range, depending upon experience.