The Care Coordinator functions as a member of an interdisciplinary team to provide care coordination to a caseload of severely mentally ill adults with multiple medical co morbidities and/or co-occurring substance abuse disorders. Advocate for and support the client, engage with community agencies/health care providers and others on his/her behalf to ensure access to services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations. Responsibilities: + Provide clinical support to the Team by providing consultation, education information around conditions, interventions, resources to maintain focus on outcomes and best practices. + Conduct initial and ongoing assessments of clients to document strengths, needs, goals and resources. + Follow up with hospital care teams during admissions and discharges to facilitate discharge planning and arranging outpatient follow-up + Assist with applications for benefits such as SNAP, SSI/SSD, HEAP + Identify and address social determinants of health such as: food insecurity, transportation, housing + Provide face-to-face outreach, engagement and service planning in the field. + Act as a linkage to community services including medical, behavioral, residential, entitlement and any other needed services per interdisciplinary care plan. + Provide crisis intervention and follow-up. + Maintain documents, records, and other related reports in an organized, timely and accurate manner as per policy and procedure. + May be assigned other tasks and duties reasonably related to the job responsibilities. Requirements: Bachelor's Degree in one of the following fields: Social Work, Psychology, Education, Rehabilitation, Occupational Therapy, Counseling, Community Mental Health, Sociology, Physical or Recreational therapy. Degrees in other related areas may be considered. Experience: + One (1) year of related human services experience required in providing direct services to clients diagnosed with severe mental illness, HIV/AIDS or other disabilities, in order to link them to a broad range of services essential to successfully living in the community. + You must have the ability and willingness to regularly travel, in some instances with clients in Agency vehicle to many locations using various modes of reliable and safe transportation + You must have excellent interpersonal and time management skills. Preferred: + Knowledge of Medicaid, Social Security, and other entitlements + Bilingual (Spanish) Benefits: + Competitive Salary + Medical/Dental + 401k (with company match) + Profit Sharing + Employee Referral Program + Lunch and Learn Workshops + Supplemental Benefits + Paid Time off + Holiday Pay Job Type: Full-time