Care Coordinator

Housing and Transitions Care Coordinator?/Discharge Care Coordinator?/Care Completion Coordinator?

The housing and transitions focused Care Coordinator helps residents of The INN Between prepare for housing, navigate discharge, and build the skills and community connections needed to remain housed. The position coordinates individualized housing and transition plans, supports participation in the Self-Reliance Life Skills Program, and provides follow-up services to residents entering housing through a post-discharge pilot.

Using a trauma-informed, strengths-based approach, the coordinator works alongside residents, the care team, and community partners to reduce barriers, strengthen independence, and maintain access to essential resources after discharge.

Housing and discharge planning

• Begin housing and discharge planning early in each assigned resident’s stay. Assess housing history, income, benefits, documentation, support networks, accessibility needs, and barriers with the resident and care team.
• Develop and update a resident-directed transition plan with achievable goals, responsibilities, timelines, and appropriate housing options aligned with the resident’s needs and preferences.
• Assist with housing applications, identification documents, benefit connections, waitlist follow-up, and referrals to housing providers and community resources.
• Coordinate with nursing, care coordinators, and outside providers to align discharge arrangements with identified care needs. Help arrange transportation, appointments, access to medications through providers, food, furnishings, and other move-in essentials.
• Provide a clear discharge plan and warm handoffs to ongoing providers. Confirm service connections, contact information, and next steps with the resident and receiving partners. Post discharge housing stability pilot
• Help implement a pilot supporting residents discharged into housing. Establish participation, consent, goals, preferred contact methods, and an individualized follow-up plan before discharge.
• Provide scheduled phone, community, or home-based follow-up, as appropriate and consistent with agency safety procedures. Assess housing stability and access to food, transportation, benefits, health care, and social supports.
• Identify emerging barriers such as missed rent, benefit interruptions, isolation, or difficulty communicating with a landlord. Coordinate timely assistance, referrals, and follow-through with the participant and relevant partners.
• Support self-advocacy and tenancy skills while connecting participants to ongoing community services.

Self Reliance Life Skills Program

• Work with residents to identify practical skills that fit their current needs, personal goals, abilities, and stage of housing readiness.
• Refer residents to relevant courses and help address participation barriers through reminders, scheduling, transportation coordination, and communication about accessibility needs.
• Reinforce learning through individual coaching and opportunities to practice skills such as budgeting, household routines, meal planning, transportation use, appointment management, and communication with service providers.
• Coordinate with instructors, volunteers, and the care team to connect coursework with each resident’s goals. Track participation and practical application, seek resident feedback, and adjust support as needs change. Collaboration and documentation
• Participate in care planning meetings and maintain relationships with housing providers, landlords, benefits programs, health and behavioral health providers, and other community partners.
• Document assessments, plans, referrals, contacts, progress, and service closures accurately and promptly in UHMIS, the electronic medical record, and other designated systems.
• Track housing placements and retention, completed resource connections, follow-up engagement, and life skills progress. Distinguish verified housing outcomes from participants whose status is unknown, and share findings to improve the pilot.
• Maintain professional boundaries and participant confidentiality. Escalate clinical concerns, safety risks, and urgent housing issues to the appropriate supervisor or provider; clinical treatment remains with qualified professionals.
• Model respect, honesty, compassion, and dignity. Communicate professionally, accept feedback, and participate in relevant training.

Qualifications

• Experience supporting people experiencing homelessness or other barriers to stability through employment, AmeriCorps service, volunteer work, or a comparable combination of experience and training.
• Strong relationship-building, organization, follow-through, documentation, and problem-solving skills; ability to support resident choice while maintaining clear boundaries.
• Ability to learn local housing and benefits systems, apply trauma-informed practices, and use agency documentation software. Relevant education in social work, human services, or a related field is preferred.
• First Aid/CPR certification or willingness to obtain; ability to meet applicable agency background screening and health requirements. A valid driver’s license and acceptable driving record are required if driving an agency vehicle is assigned.