Social Worker-Coordinated Entry, Triage, & Care Coordination

• Department: Senior Housing Services (SHS)
• Status: Full time, Exempt
• Hours: Monday – Friday, 8:30am-5:00pm. Occasional nights or weekends
• Compensation: $85,000 – $95,000 (MSW/ASW)
• Reports To: Clinical Director of Housing Services

About Us

St. Mary's Center is a community of hope, healing and justice dedicated to improving the well-being of Seniors and Preschool Families in West Oakland by meeting basic needs for food, housing, and social connection. We build on a strong foundation of direct service provision and participant-led advocacy that amplifies the voices of people directly impacted by hunger, homelessness, and inequity to create a more just and caring society.

Today, our staff of 40 provides Senior Homeless and Housing Services, including case management and housing clinics; transitional housing at multiple sites; and a vibrant Community Center offering hot meals, social connection, and leadership development. We are partnered with a local nonprofit developer to build and service 73 new homes for Seniors near our headquarters

Position Summary

The Social Worker – Coordinated Entry, Triage & Care Coordination serves as the primary assessment and triage specialist for Senior Housing Services. This position is responsible for Housing Clinic assessments, Coordinated Entry activities, participant prioritization, care coordination, crisis screening, and recommendations regarding housing interventions and supportive services.

The Social Worker serves as the primary entry point into housing services and ensures participants are appropriately connected to Housing Navigation, Transitional Housing, Tenancy Sustaining Services, healthcare, behavioral health, and community resources.

The position does not typically carry an ongoing housing case management caseload and instead focuses on assessment, triage, care coordination, and participant access.

Essential Duties and Responsibilities

• Coordinated Entry & Housing Assessments (35%)
• Conduct Coordinated Entry assessments and reassessments.
• Complete housing needs assessments.
• Evaluate participant eligibility for housing programs.
• Assess barriers to housing stability.
• Determine housing intervention recommendations.
• Support participant prioritization and referral activities.
• Ensure compliance with Alameda County Coordinated Entry requirements and contractual obligations.

• Housing Clinic Operations (20%)
• Conduct participant assessments during Housing Clinic.
• Review participant housing needs and service requests.
• Provide recommendations regarding housing pathways.
• Support participant engagement and navigation.
• Coordinate referrals into Housing Navigation and Transitional Housing programs.

• Triage & Care Coordination (20%)
• Conduct crisis screening and risk assessments.
• Coordinate referrals to healthcare, behavioral health, substance use, APS, IHSS, ECM, and supportive services.
• Facilitate warm handoffs to internal and external service providers.
• Assist participants in accessing appropriate community resources.
• Support participant-centered service planning.

• Case Conferencing & Clinical Consultation (10%)
• Participate in multidisciplinary case conferences.
• Consult with Housing Services staff regarding participant needs.
• Collaborate with the external partners regarding high-risk participants.

Assist with complex participant situations and service planning to ensure closed loop referrals and quality follow-up

• Community Partnerships & Systems Coordination (5%)
• Participate in Coordinated Entry and regional meetings.
• Maintain relationships with referral partners.
• Coordinate participant referrals across systems of care.

• Documentation & Compliance (10%)
• Maintain timely HMIS and Salesforce documentation.
• Complete assessment and referral documentation.
• Support quality assurance activities.
• Ensure compliance with program requirements and documentation standards.
• Performance Expectations
• Coordinated Entry assessments completed timely.
• Housing Clinic operations supported effectively.
• Appropriate referrals and service recommendations provided.
• Documentation standards maintained.
• Participant access barriers reduced.
• Compliance standards achieved.
• Community partnerships maintained.

Minimum Qualifications

• Master’s Degree in Social Work (MSW) or related field.
• Registration as an ASW or eligibility for registration preferred.
• Three years of experience in homelessness services, housing services, behavioral health, healthcare, or supportive services.
• Experience conducting assessments and care coordination.
• Experience working with vulnerable populations.
• Valid California Driver’s License.

Preferred Qualifications

• Licensed Clinical Social Worker (LCSW).
• Experience with Coordinated Entry, HMIS, Housing First, and CalAIM.
• Experience serving older adults experiencing homelessness.
• Bilingual or multilingual skills.

General Staff Expectations

Promote a safe, respectful, and inclusive environment.

Support the mission and values of St. Mary’s Center.

Maintain professionalism and confidentiality.

Follow agency policies and procedures.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. In general, while performing the duties of this job, the employee is expected to stand; walk; sit; reach with hands and arms; and talk or hear.

• Ability to sit, stand, walk, bend, and communicate effectively throughout the workday.
• Ability to travel to participants at community sites.
• Ability to occasionally lift and/or move up to 20 pounds.
• Ability to use computers, phones, tablets, and related technology for documentation and communication.

Equal Employment Opportunity

St. Mary’s Center is an equal opportunity employer and is committed to an active Equal Employment Opportunity. We celebrate diversity and are committed to an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information or veteran status.

In compliance with the California Fair Chance Act, St. Mary’s Center will consider qualified applicant with a criminal history pursuant to the California Fair Chance Act.