Position Title: Community Living Coordinator

Position Summary:

Serves as a front-line provider for the Agency information and assistance, person-centered options counseling and SHIP/MIPPA functions. Provides options counseling and resource navigation services, supports outreach functions, educates referral sources, completes reports, drafts correspondence, and enters data using multiple software programs. Supports service arrangement functions for funded programs that provide in-home services through various funding sources.

Works with Community Living team to ensure the team provides person-centered services to individuals over 60, adults with disabilities, and caregivers, helping them navigate long-term community support tailored to their personalized needs and preferences. The focus is on self-empowerment and equipping individuals with the knowledge and tools to make informed decisions and thrive in their community.

Key Responsibilities:

Conducts comprehensive assessments of needs and preferences and provides information on resources, such as basic needs, housing, home modifications, assistive technology, transportation, employment, healthcare, and in-home services. Supports individuals in facilitated decision-making, helping them weigh options, consider outcomes, and make informed choices aligned with their values and goals. Services are delivered via phone, video conferencing, email, or in-person meetings.

Connects individuals to services, advocates in partnership with individuals for access to resources, and offers case coordination for individuals at risk of nursing facility placement. Follow-up services are provided to ensure individuals receive the services they need that align with their preferences while addressing any evolving or additional needs.

Additionally, the role involves conducting outreach presentations to raise awareness of options counseling services and building collaborative relationships with community partners to strengthen service delivery.

Supports transitional care management needs for participant cases by coordinating with discharge planners, primary care staff, and other health care providers to support successful transitions and avoid re-hospitalization, considering psycho-social barriers and self-management support. 

Must be able to travel to offsite assignments.

Must be able to visit clients in many different environments.

Supports the achievement of Agency mission, vision, and reflects its values in work behavior and performs other duties as assigned.

Education and Experience:

• High school diploma or GED required.
• CHW certification obtained within one year of employment. CareWell may cover the cost of obtaining the CHW certification.
• Experience in serving a diverse population in urban or rural environments with the familiarity of resource networks preferred. 

Limitations and Disclaimers:

The above job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required for the position.

This job description does not state or imply that these are the only duties to be performed by the employee occupying this position. Employee will be required to follow any other job-related instructions and to perform other job-related duties requested by their supervisor in compliance with federal and state laws.

Requirements are representative of minimum levels of knowledge, skills and/or abilities. To perform this job successfully, the employee must have the abilities or aptitudes to perform each duty proficiently. Continued employment remains on an “at-will” basis.