Specialist, Care Coordination

HOMAGE SENIOR SERVICES•Everett, WA

2d•$24 - $38•Hybrid

About The Position

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.

Requirements

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 Assistant
2-3 years of experience in case management and care coordination
Proficiency in electronic health platforms
Demonstrated ability to work independently while effectively coordinating with staff, clients, and community partners
Strong organizational and prioritization skills to thrive in a fast-paced environment
Knowledge and application of Trauma-Informed Care practices
Effective critical thinking and problem-solving abilities
Strong verbal and written communication skills
Familiarity with healthcare delivery systems and community resources
Willingness to work in varied client environments, including those with strong odors, pets, or cigarette smoke
Proficiency in Microsoft Office Suite (Outlook, Teams, Excel, Word, PowerPoint) and internet navigation
Valid WA State driver’s license and current automobile insurance

Nice To Haves

Master’s Degree in Social Work, Psychology, Social Services, Human Services, or Behavioral Sciences
Experience working with elder and disabled populations
Experience engaging with diverse communities
Fluency in languages other than English

Responsibilities

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.
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.
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.
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.
Maintains accurate, timely documentation in designated electronic health systems, such as Julota database.
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.
Performs other duties as assigned to support program goals and organizational objectives.