Care Coordinator

Position Summary

Thistle Farms is a nonprofit social enterprise dedicated to helping women survivors recover and heal from prostitution, trafficking, and addiction. We do this by providing a safe place to live, meaningful jobs, and a lifelong sisterhood of support.

The Care Coordinator plays a vital role in supporting women throughout their healing and recovery journey at Thistle Farms by providing comprehensive case management and care coordination throughout the two-year residential program. The position assesses resident needs, develops individualized care plans, coordinates internal and external resources, advocates for residents, monitors progress, and supports transitions into permanent housing and independent living. Working closely with the Manager of Residential Care & Support and interdisciplinary team, the Care Coordinator helps foster a safe, welcoming, trauma-informed environment where residents build trust, strengthen life skills, increase self-sufficiency, and achieve individualized recovery goals.

Position Responsibilities

Essential Responsibilities

1. Case Management and Resident Support

- Builds supportive, trauma-informed, strengths-based relationships with residents and maintains an active caseload of up to ten (10) residents.

- Conducts comprehensive biopsychosocial and resource assessments upon admission in conjunction with the Clinical Director and develops individualized care plans with each resident.

- Meets with residents weekly during the first 120 days and bi-weekly thereafter, or more frequently based on resident need, to review goals, assess progress, and identify barriers.

- Monitors progress toward treatment, recovery, housing, employment, educational, and independent living goals.

- Utilizes motivational interviewing and trauma-informed practices to promote resident engagement, self-determination, healthy routines, budgeting, problem-solving, decision-making, and independent living skills.

- Supports residents through transitions between levels of care and housing within the Thistle Farms continuum.

2. Benefits and Resource Coordination:

- Coordinates and assists residents with obtaining identification documents and accessing public benefits, including TennCare/Medicaid, SNAP, TANF, and SSI/SSDI when applicable.

- Connects residents with healthcare, behavioral health, dental and vision care, medication assistance, transportation, legal aid, employment and workforce development, educational and vocational opportunities, financial literacy resources, and community support organizations.

3. Program Coordination and Advocacy:

- Coordinates resident appointments, referrals, transportation, and follow-up services and monitors participation in required programming and supportive services.

- Collaborates with the Clinical Director to implement and update individualized care plans and assists with resident orientation and onboarding.

- Maintains communication with community partners and service providers, participates in interdisciplinary staffing meetings and case consultations, and advocates for residents with outside agencies and providers.

4. Housing and Discharge Planning:

- Begins discharge planning upon admission and assists residents in identifying long-term housing options.

- Coordinates housing applications and supportive housing referrals and develops individualized transition plans for successful program completion.

- Ensures residents have established medical, behavioral health, employment, and community supports prior to discharge and provides follow-up resource coordination as appropriate.

5. Community Living Support:

- Fosters a respectful, safe, recovery-oriented residential community and supports implementation of community expectations and residential policies.

- Models healthy boundaries and positive communication, assists with conflict resolution using restorative and trauma-informed practices, and responds appropriately to resident concerns, crises, and emerging needs.

- Participates in Care & Concern meetings and wellness planning and supports healthy peer relationships and community engagement.

6. Documentation and Compliance:

- Maintains timely, accurate, and objective documentation in Apricot and other required systems, including assessments, care plans, progress notes, referrals, and discharge documentation.

- Completes documentation within established timeframes, monitors resident outcomes, and supports data collection, quality improvement, grant reporting, and program evaluation.

- Ensures compliance with organizational policies, licensing standards, confidentiality requirements, and funder expectations.

Additional Responsibilities

- Participates in weekly multidisciplinary team meetings, supervision, case staffing, documentation audits, and organizational trainings.

- Collaborates with residential staff to ensure continuity of care and maintains professional relationships with community partners and referral agencies.

- Participates in agency committees, special projects, program development initiatives, and continuous quality improvement efforts as assigned.

- Maintains current knowledge of trauma-informed care, recovery-oriented practices, community resources, and government assistance programs.

- Maintains flexibility to meet resident and program needs, including occasional evenings, weekends, holidays, transportation of residents, and participation in the residential on-call rotation.

- Performs other duties as assigned.

Qualifications

Minimum Requirements

Education and Experience

Bachelor’s degree in Social Work, Human Services, Psychology, Counseling, Criminal Justice, or a related field preferred. Equivalent education and experience may be considered. Minimum of two years of experience providing case management or direct services to individuals impacted by trafficking, addiction, homelessness, incarceration, trauma, exploitation, or behavioral health challenges preferred. Valid driver’s license with an acceptable driving record and the ability to transport residents as needed.

Physical Requirements

- Position requires prolonged periods of sitting, standing, walking, and working on a computer; local travel to accompany residents to appointments and community resources; occasional lifting of up to 15 pounds; and the ability to respond calmly and effectively in crisis situations.

Skill Competencies

- Demonstrates knowledge of trauma-informed care, harm reduction, strengths-based practice, and survivor-centered approaches.

- Demonstrates experience navigating public benefits and community resources.

- Demonstrates strong assessment, advocacy, crisis intervention, and problem-solving skills.

- Demonstrates excellent verbal, written, organizational, and documentation skills.

- Demonstrates the ability to manage multiple priorities while maintaining attention to detail.

- Demonstrates the ability to establish and maintain professional boundaries while building trusting relationships.

- Demonstrates proficiency with electronic health records or case management software; Apricot experience is preferred.

- Demonstrates effective collaboration with interdisciplinary teams and community partners.

- Demonstrates a commitment to Thistle Farms’ mission and core values.

Thistle Farms provides equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunities apply to all terms and conditions of employment. Thistle Farms reserves the rights to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains “At-Will.”