Social Services Coordinator, Post-Hospital Care & Housing
Overview
You will own post-hospital care services for guests transitioning from acute care, managing a caseload of 25+ guests with Needs Assessments, Care Plans, and discharge coordination. You'll collaborate with a nursing team for weekly case conferencing and partner with community organizations for mental health and housing referrals. This role blends direct guest engagement, harm reduction practices, and CRM documentation to ensure seamless transitions. You'll drive outcomes through Coordinated Entry System compliance and Homeless Management Information Systems data entry. Your daily check-ins build trust and rapport, making a tangible impact on housing stability.
What You'll Do10
- 1Complete Needs Assessments and Care Plans within 90 days, ensuring timely and accurate documentation.
- 2Refer guests to mental health and housing services, coordinating with external case managers.
- 3Facilitate discharge from hospitals and locate housing for 25+ guests, using bed board for census planning.
- 4Maintain CRM databases daily and update partner contacts to track guest progress.
- 5Complete Coordinated Entry System documents and Homeless Management Information Systems entries for compliance.
- 6Conduct daily check-ins with guests, building rapport and trust while applying harm reduction and motivational interviewing.
- 7Collaborate with the nursing team to run weekly case conferencing and attend care coordination meetings.
- 8Provide emergency referrals for domestic violence, human trafficking, and sexual assault with warm handoffs.
- 9Support guest interventions including de-escalation and crisis prevention, and conduct contraband searches when applicable.
- 10Maintain compliance with HMIS and funder standards, adapting to schedule changes and home visits when needed.
Requirements10
- 1Bachelor’s Degree required, Master’s in Social Work preferred.
- 23+ years in healthcare delivery, hospital education, or social services.
- 3Proven ability to present information to directors, case managers, and discharge planners.
- 4Excellent oral and written communication skills.
- 5Strong time management and organizational skills.
- 6Computer proficiency in MS Word, Excel, Outlook, PowerPoint and typing.
- 7Reliable transportation and flexibility for home visits.
- 8Bilingual Spanish preferred.
- 9Pass background check, LIVE scan, and TB test.
- 10Physical ability: stand, walk, lift up to 50 pounds, hear alarms, operate dual screens.
Salary Insight
$54k per year
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