Work 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 the North Bay.
We are hiring a new Short-Term Post Hospitalization (STPH) Navigator to join our Helen Vine Recovery Center program. In this role you will provide direct, client-centered wrap-around case management support to individuals transitioning from higher levels of care (e.g., hospital, detox, incarceration, residential treatment, crisis services) into community-based services. You will play a key role in delivering Community Supports (CS) and Enhanced Care Management (ECM) services by assisting clients in accessing care, coordinating services, and reducing barriers to housing stability and recovery.
Under the direction of the Navigation Manager, you will support a closed-loop referral process, ensuring that referrals to housing, behavioral health, medical, and social services are completed and tracked. This role requires strong attention to documentation standards and Partnership Health Care Medi-Cal service requirements, ensuring that all services are accurately recorded to support program compliance, billing, and quality outcomes. This is a full-time day shift position working Monday through Friday with evenings as needed.
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, including:
Housing Transition Navigation Services (HTNS)
Housing Deposits
Housing Tenancy & Sustaining Services (HTSS)
Short-Term Post Hospitalization (STPH) housing
Enhanced Care Management
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
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 (TARs)
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 (what was done)
Purpose of service (why it was needed)
Outcome or next steps
Participate in training and ongoing learning related to:
Medi-Cal documentation standards
CalAIM ECM and Community Supports service requirements
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.
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.
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
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
Valid California Driver’s License and insurable driving record
Access to a personal vehicle (mileage reimbursed)
First Aid/CPR certification may be required
Ability to sit, stand, walk, and drive for extended periods
Occasional lifting up to 25 pounds
Frequent computer use and documentation
Ability to travel within Sonoma and Marin Counties
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.
