Provide trauma-informed, person-centered case management and proactive community outreach for adults with developmental and intellectual disabilities. Coordinate cross-sector supports across health, housing, and justice systems to reduce risk and improve stability for clients.
Requirements summary
Requires a Bachelor's degree in Social Services or Mental Health and 3 years of experience in the developmental service sector. Must possess deep knowledge of harm reduction, concurrent disorders, and the social determinants of health.
Reporting to the Director of Services, the Intensive Case Coordinator provides trauma-informed, person-centered case management to adults with developmental and intellectual disabilities who are experiencing complex barriers to wellness. This role is highly community-based and involves proactive outreach—working on the ground with community partners to identify, engage, and support individuals who may not be effectively reached through existing service pathways.
The Intensive Case Coordinator leads the development, facilitation, coordination, monitoring, and ongoing updating of individualized plans in collaboration with individuals, caregivers, and service providers. The role includes strengths-based assessment, service navigation, advocacy, and follow-up to reduce risk, improve stability, and increase access to appropriate supports. Services are delivered both in person and remotely, based on individual needs and in a manner that promotes dignity, choice, and cultural safety.
Building strong working relationships across health, addictions, housing, justice, and social service systems is central to this position. The Intensive Case Coordinator coordinates, “hand-offs” between agencies, helps remove barriers such as missed appointments, transportation, and communication challenges, and ensures timely follow-up so supports do not fall away. Accurate documentation, collaborative problem-solving, and a flexible, mobile approach are required to meet individuals where they are and help connect them to consistent, sustainable care.
Key Responsibilities/Duties
Build non-judgmental, trust based relationships with individuals who use substances and may experience houselessness, mental illness, or criminalization using trauma informed culturally safe, and person-centered approaches to support client autonomy.
Conducting in-depth assessments of individuals’ housing, health, substance use, income, legal, and social needs identifying strengths, risks, goals, and objectives that align with their cultural values and traditional collaboration with the client.
Obtain the required resources and services and support them in identifying alternative resources to meet service gaps. Respond to housing instability using harm reduction strategies and deescalation techniques providing emotional support and connecting clients with urgent resources (shelters, detox, mobile crisis teams).
Provide support such as accompanying individuals to appointments, helping complete forms, or facilitating referrals.
Conducts outreach in encampments, drop ins or street-based settings to connect with hard-to-reach clients.
Maintain regular contact with individuals to reassess goals, track progress and adjust support, reassessing for safety concerns.
Support collaborative contracts with community services including those within the criminal justice system, mental health, and health care systems, etc.
Coordinate cross sector in system navigation support for case resolution example assessments, clinical planning, housing, urgent response, integrated response committee, etc.
Build relationships with peer leaders, grassroots harm reduction groups, and service providers.
Implement and maintain documentation and data in Microsoft, SharePoint, CRM system as required.
Maintain accurate, timely case notes reflecting client interactions, progress, and needs.
Update care plans and risk assessments in line with harm reduction principles.
Ensure confidentiality and secure storage of client information in accordance with privacy laws.
Schedule and confirm appointments with individuals including internal services and external references.
Attend regular team meetings, supervision sessions, and interagency case conferences.
Share relevant updates on client progress, emerging trends, or service gaps.
Stay current with agency protocols, harm reduction, best practices, and legal requirements. Complete required training regarding confidentiality, cultural safety and overdose response.
Partner with various agencies to leverage and coordinate services to ensure that individuals and caregivers meet their individual support needs.
Provide services and support to individuals, meeting with them in the community at the agency or accompanying them to community appointments.
Ensure proper consents are completed for reports to be released from clinicians and explain nature of consent.
Arrange follow-up appointments with individuals’ caregivers and clinicians as needed.
Provide information to individual families, support workers, and other community professionals.
Ability to receive and process all applications for services, reviewing information to determine eligibility for support and identify nature and extent of support requested.
Ability to look at the community first, to collaborate and build individualized solutions and to explore resources and programs available to all individuals.
Qualifications
Bachelor's degree in Social Services, Mental Health Science or Social Service Worker.
3 years of experience working in the developmental service sector or a combination of education, training and experience supporting people with developmental and intellectual disabilities.
Extensive knowledge and experience with trauma, addictions, mental health and houselessness.
Demonstrate knowledge and skill in group facilitation, planning and case management, and the ability to promote and build consensus and resolutions.
Highly developed interpersonal communication, both written and oral, organization, problem solving, advocacy, interviewing and active listening skills.
Comprehensive theoretical and practical knowledge of the principles of harm reduction, trauma and concurrent disorders, and social determinants of health.
Training or experience in cultural competency or cultural humility is preferred.
Demonstrate ability to network and develop plans for complex issues.
Proficient with Microsoft (Word, Excel, Power Point and Outlook).
Core Competencies
Core competencies describe the values, traits, and behaviours that guide how we do our work when supporting people with developmental disabilities. The competencies below reflect the developmental services sector expectations and align with this community-based, cross-sector case management role.
Advocacy
Building Relationships
Problem Solving & Decision Making
Resilience
Valuing Equity, Diversity, and Inclusion (EDI)
Resource Management
Strategic Thinking
Championing Change and Innovation
Facilitating Growth and Development
Inclusive Leadership
Working Conditions
This position is primarily community-based and requires flexibility to meet individuals where they are. Working conditions may include, but are not limited to:
Regular work in the community with some office-based/virtual work (e.g., partner agencies, shelters/drop-ins, health-care settings, individuals’ homes, and other community locations).
Frequent local travel; a valid driver’s license and access to reliable transportation may be required based on program needs.
Schedule may include occasional evenings and/or weekends to support client engagement and attend community meetings or case conferences.
Work occurs in non-traditional environments and may involve unpredictable situations, limited privacy, and varying levels of noise, activity, or weather conditions.
Potential exposure to emotionally demanding situations (e.g., crisis, trauma, grief) and to settings where substance use is present; requires strong boundaries, self-care practices, and use of de-escalation strategies.
The role requires adherence to agency safety procedures, including working alone/community visit protocols, incident reporting, and use of personal protective equipment as required.
Physical demands may include extended periods of walking/standing, stair climbing, and carrying work materials (e.g., laptop, files, supplies).
Regular computer and phone use for documentation, scheduling, virtual meetings, and data entry (e.g., Microsoft 365/SharePoint/CRM).
Requires the ability to manage confidential information in community settings and always follow privacy legislation and organizational policies.
