Short-Term post hospitalization navigator

Job DetailsLevel

• ExperiencedJob
• Location:
• Sonoma -
• Santa
• Rosa,
• CA 95407Position
• Type:
• Full
• TimeSalary
• Range: $28.00 - $30.00
• HourlyJob
• Category: Health CareWork with great people doing great things! Join Buckelew Programs and play a pivotal role in making a meaningful impact on the lives of individuals facing mental health and substance use challenges in Sonoma County. We are hiring a Short-Term Post Hospitalization (STPH) Navigator to provide client-centered, wrap-around case management for individuals transitioning from hospitals, detox, incarceration, residential treatment, or crisis services into community-based care. This role supports Community Supports (CS) and Enhanced Care Management (ECM) services by helping clients access care, coordinate services, and overcome barriers to housing stability and recovery. Under the direction of the Navigation Manager, the Navigator manages closed-loop referrals to housing, behavioral health, medical, and social services, ensuring services are completed, tracked, and documented in compliance with Partnership HealthPlan Medi-Cal requirements for program quality and billing.

Responsibilities

Client Navigation and Care Coordination Provide direct navigation services to clients transitioning from hospitals, residential treatment, crisis services, incarceration, and other higher levels of care. Assist clients in accessing CS and ECM services Support clients in accessing medical, mental health, substance use, legal, and social services. Coordinate care across providers to ensure continuity and reduce service gaps. Housing Support & Stability Assist clients in identifying and securing appropriate housing options. Support completion of housing applications, documentation, and eligibility requirements. Connect clients to rental assistance, deposit funding, and community housing resources. Provide tenancy support, including lease education, communication with landlords and basic life skills to support housing stability Documentation, Billing Support & Compliance Complete timely, accurate, and compliant documentation in the Electronic Health Record (EHR) to support Medi-Cal billing requirements, treatment Authorization Requests and Community Supports and ECM service delivery Document all client interactions, services provided, and outcomes in alignment with program and regulatory standards. Ensure documentation clearly reflects service provided, purpose of service and outcome or next steps. Participate in training and ongoing learning related to Medi-Cal documentation standards, CalAIM ECM and Community Supports service requirements and audit readiness and compliance expectations. Support internal audits and quality assurance processes by maintaining complete and accurate records. Closed Loop Referrals & Service Tracking Initiate, track, and follow up on referrals to ensure services are accessed and completed. Maintain accurate records of referral status, including: Referral initiation Outreach and Engagement attempts Service linkage Referral closure outcomes Communicate referral updates with care team members and community partners. Client Engagement & Support Build rapport using a trauma-informed, person-centered approach. Engage clients who may be hesitant or difficult to reach. Support clients in identifying goals and taking steps toward housing stability and recovery. Encourage self-advocacy and independence. Care Team Collaboration Participate in multidisciplinary team meetings and case reviews. Communicate regularly with Navigation Managers regarding client progress and barriers. Collaborate with ECM providers, hospitals, and community partners. Outreach & Community Connections Maintain knowledge of community resources, including housing, medical, and behavioral health services. Build relationships with community providers to support referral pathways. Assist with outreach and engagement efforts. Education and Experience Bachelor’s degree in Social Science, OR Peer Support Specialist Certification, Patient Navigation Certification, Community Health Certification, Alcohol & Drug Counseling Certification, or equivalent experience Minimum of 1–3 years’ experience working with: Individuals with mental health and/or substance use challenges Housing navigation, case management, or community-based services Lived experience strongly preferred Professional Skills Proficiency with Microsoft Word, Excel, Google Workspace, EHR systems, and office technology. Understanding of community resources and behavioral health systems Ability to navigate complex service systems Excellent verbal and written communication and engagement skills Strong organizational and time management skills Ability to work independently and within a team Cultural competence and ability to serve diverse populations Experience with Electronic Health Records (EHR) preferred Timely documentation Flexibility to work occasional evenings or non-standard hours. Compliance with program and payer requirements Additional Requirements Valid California Driver’s License and insurable driving record and ability to travel within Sonoma and Marin Counties Access to a personal vehicle (mileage reimbursed) Ability to pass LiveScan background check First Aid/CPR certification may be required Great Benefits! Medical, dental, vision, life and long-term disability insurance, Employee Assistance Program, flexible spending accounts for health, dependent and transit costs, retirement savings plan with company match, eligibility for loan forgiveness, continuing education credits available through our learning management system, discount program, paid meal breaks and generous paid time off. We are an Equal Opportunity Employer committed to creating a workplace that celebrates diversity, promotes equality, and fosters inclusion. We encourage applications from individuals of all backgrounds, experiences, and perspectives.