We are an FQHC community health center dedicated to embodying the values central to American Indian cultures.
This includes respect for our patients, acknowledgement of the whole person, and a focus on working together to ensure health for the individual, and therefore the community.
We invite persons of all tribes, ethnic backgrounds and walks of life to experience the comprehensive care we deliver and to contribute to the services we provide for children, youth, families, adults, and elders.
The Care Coordinator (SAPTA Program) coordinates care for patients receiving substance use disorder (SUD) prevention, treatment, and recovery support services funded in whole or in part by the SAMHSA Substance Abuse Prevention and Treatment (SAPTA)Grant.
The Care Coordinator serves as a primary point of contact for patients, linking them to medical, dental, behavioral health, traditional healing, peer support, and community services, and ensuring timely, coordinated, culturally responsive care.
The Care Coordinator works closely with the Behavioral Health team, Traditional Healer, Natural Helpers, Community Health Workers, and external treatment providers to remove barriers to care, support patient engagement and retention, and meet SAPTA Grant requirements, including timely access for grant priority populations, required data collection and reporting, and compliance with federal confidentiality rules.
Essential
Duties and Responsibilities
Primary Functions: Serve as the primary point of contact for patients engaged in SUD prevention, treatment, and recovery services; develop, maintain, and update coordinated care plans in collaboration with the clinical team and the patient. Coordinate intake, screening follow-up, and warm handoffs for patients referred to SUD services, ensuring timely engagement and appropriate level-of-care placement in coordination with licensed clinical staff. Prioritize timely access to services for SAPTA Grant priority populations consistent with grant requirements (including interim services when treatment capacity is unavailable). Coordinate referrals and linkages to internal services (medical, dental, behavioral health, Traditional Healer, Natural Helper peer support) and external providers, including withdrawal management, residential treatment, medications for addiction treatment (MAT/MOUD), recovery housing, and social services; track all referrals to completion and document outcomes. Conduct proactive follow-up contacts to support patient engagement and retention in treatment and recovery services, including appointment reminders, re-engagement outreach after missed appointments, and coordination of transportation. Assist patients in overcoming barriers to care, including benefits enrollment (e.g., Medi-Cal), housing, food security, childcare, transportation, and employment resources, in collaboration with Case Managers and Community Health Workers. Maintain accurate, timely documentation in the electronic health record consistent with SDCHC policies, HIPAA, and 42 CFR Part 2 (confidentiality of SUD patient records), including management of patient consent-to-disclose forms for care coordination. Collect, enter, and submit grant-required data within required timeframes; support preparation of SAPTA Grant reports; and participate in program evaluation and continuous quality improvement activities. Coordinate culturally grounded care by integrating Traditional Healer and Natural Helper services into care plans when requested by the patient, ensuring that participation in cultural or spiritual components of care is voluntary and that patients are informed of their right to decline such services, consistent with SAMHSA Charitable Choice requirements (42 CFR Part 54/54a). Support crisis coordination by connecting patients to crisis services and following SDCHC protocols; escalate clinical concerns to licensed staff. Care coordination is provided as an adjunct to—not a substitute for—clinical behavioral health and SUD treatment. Participate in community outreach, education, and prevention activities that promote awareness of SUD prevention, treatment, and recovery resources in the urban AI/AN community. Attend regular team meetings, trainings, and supervision, including trauma-informed care, motivational interviewing, cultural humility, overdose prevention and naloxone administration, and other trainings required for the SAPTA Program. Other Duties as assigned Required Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The qualifications below represent the required knowledge, skills, and/or ability. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. High school diploma or GED required; associate or bachelor’s degree in health, human services, social work, or a related field preferred. Minimum of one (1) year of experience in care coordination, case management, patient navigation, or a related role, preferably in a substance use disorder, behavioral health, or community health setting. Ability to work respectfully with diverse tribal backgrounds and urban AI/AN populations, with demonstrated cultural humility and understanding of historical trauma. Effective communication, interpersonal, and organizational skills, including the ability to manage a caseload, track referrals, and meet documentation and reporting deadlines. Ability to maintain strict confidentiality consistent with HIPAA and 42 CFR Part 2, and willingness to work flexible hours, including occasional evenings and weekends, as needed.
