Bilingual Community Based Care Coordinator

POSITION SUMMARY

The Community Based Care Coordinator works in direct service, responsible for delivering high-quality Health-Related Social Needs (HRSN) care coordination, including Outreach & Engagement (O&E) and Tenancy Supports. This role is essential in advancing Neighborhood House’s whole-person care approach, ensuring that clients receive timely, culturally responsive, and compliant support.

JOB DUTIES & RESPONSIBILITIES

DIRECT SERVICE & CARE COORDINATION

• Work with HRSN referrals to assess eligibility for the OHP HRSN Medicaid benefit and work with eligible clients to provide both short and long-term support.
• Provide Outreach and Engagement services, including screening for needs, creating short action plans, and connecting members to resources.
• Hold a case load of 28-30 clients (full time).
• Provide Tenancy Support and Procurement services once housing supports are authorized.
• Develop and update individualized care plans, incorporating client voice, goals, and priorities.
• Deliver trauma-informed, culturally responsive services with a strong equity lens.
• Maintain accurate, timely documentation of all client contacts in the client management system.
• Support clients with applications for HRSN services, benefits, or other resources.
• Coordinate warm handoffs with internal NH programs (Food Security, Education, Senior Services) and external partners.

GENERAL PROFESSIONAL RESPONSIBILITIES

• Attend and actively participate in required meetings and training sessions.
• Maintain timely and professional communication with coworkers, leadership, and stakeholders.
• Demonstrate regular and reliable attendance.
• Complete assigned work accurately and within established deadlines.
• Follow organizational policies, procedures, and safety requirements.
• Contribute to a positive, respectful, and team-oriented work environment.
• Perform other duties as assigned.

REQUIRED SKILLS AND QUALIFICATIONS

To perform the job successfully, an individual should demonstrate the following competencies:

INTERPERSONAL & DIRECT SERVICE SKILLS

• Strong interpersonal and communication skills to effectively engage with diverse clients, staff, and stakeholders.
• Demonstrated ability to work effectively with diverse populations, including immigrant and refugee families, and people from various cultural backgrounds.
• Ability to apply trauma-informed and culturally responsive approaches in client interactions.
• Capacity to serve as a peer trainer/coach, helping others adopt new systems and workflows.

GENERAL PROFESSIONAL SKILLS

• Ability to work independently while collaborating with a multidisciplinary team.
• Knowledge of health and social service systems, including Medicaid and community-based resources.
• Adaptability and flexibility to support ongoing program development and process improvements.
• Proficiency in Microsoft Office (Word, Excel), Outlook, Teams, and comfort learning and using client data/documentation systems.
• Ability to handle confidential and sensitive information with discretion and professionalism.
• Strong organizational and time management skills, with the ability to manage multiple tasks and deadlines.

REQUIRED EDUCATION AND EXPERIENCE

REQUIRED:

• Minimum 3 years of experience in community health work, social work, case management, client advocacy, or social services.
• Bilingual in English and Spanish, or English and Ukrainian 
• Proficiency in data entry, documentation, and maintaining organized records.
• Strong understanding of social determinants of health and barriers to accessing services.
• Experience in outreach, referral navigation, or connecting clients to health and social services.
• Experience working with unhoused individuals as well as vulnerable and disadvantaged populations.
• Associate’s degree in social work or related field, or equivalent experience. 

PREFERRED:

• Experience working with or within a community-based organization.
• Familiarity with Medicaid, the Oregon Health Plan, or HRSN services.
• Knowledge of documentation systems and program evaluation.
• Bachelor's degree in social work or related field.

REQUIRED CERTIFICATES, LICENSES, CREDENTIALS AND/OR REGISTRATIONS

• Valid driver’s license and car insurance that meets the requirements of NH’s auto insurance provider.
• Community Health Worker certificate

PHYSICAL REQUIREMENTS

The physical requirements outlined below must be met to successfully perform the essential functions of this position. Reasonable accommodations may be provided to enable individuals with disabilities to perform these essential functions.

While performing the essential duties of this job, the employee is required to:

• Communicate information clearly so others understand and exchange accurate information.
• Observe details at close range. 
• Remain in a stationary position.
• Operate a computer and other office machinery, such as copy machine and printer.
• Walk, stoop, kneel, crouch.
• Move items weighing up to 50 pounds.

ENVIRONMENTAL WORKING CONDITIONS

The work environment characteristics described below are representative of those an employee encounters while performing the essential functions of this position. 

While performing the duties of this job, the employee is occasionally exposed to moderate noise levels typical of an office environment.