🔎 Role snapshot

• Coordinates services, community supports, and resource linkage for residents.

• Acts as the primary liaison between residents, families, the agency, and external service providers.

• Supports access to benefits, housing, transportation, and other community resources; helps navigate waivers, eligibility, and authorizations.

🎯 Core qualifications (typical)

• Education: Bachelor’s degree in social work, psychology, sociology, human services, or a related field; or equivalent experience.

• Experience: Prior case management or care coordination experience in IDD/HCBS, vocational support, or community-based services.

• Background checks: Successful completion of fingerprint/background checks per HHSC/employer policy.

• Licensing/credentials: Not always required to hold a professional license; certifications such as CSW/LBSW or case management credentials may be preferred depending on the agency.

• Communication & documentation: Strong written and verbal communication; proficient in maintaining service plans, progress notes, and coordination records.

🧭 Key responsibilities

• Conduct needs assessments and develop individualized service plans in collaboration with residents, families, and the care team.

• Link residents to community resources (benefits; housing; transportation; employment supports; respite; day programs).

• Coordinate with Medicaid waivers, service providers, therapists, and nursing to ensure seamless service delivery.

• Monitor progress toward goals; adjust plans as needed; escalate barriers to appropriate team members.

• Maintain case notes, service plans, authorization documents, and compliance records.

• Facilitate crisis planning and referrals to appropriate supports when needed.

🧩 Collaboration & supervision

• Interface with internal staff (DSPs, RNs/LPNs, QC/QA, Activities; etc.) and external providers (social services, community agencies, vendors).

• May operate under the supervision of a Program Director or Case Management Lead, depending on agency structure.

• Ensure resident rights, confidentiality (HIPAA), and culturally competent engagement.

🛡️ Health, safety, and compliance

• Ensure activities and services align with TAC/HHSC requirements and least-restrictive approaches.

• Coordinate with nursing and clinical staff on health-related service needs and safety concerns.

• Documentation and reporting in accordance with agency policies and regulatory requirements.

🧾 Administrative notes

• Track service authorizations, timelines, and billing milestones where relevant.

• Maintain organized files (intake, service plans, progress notes, communications with families).