Care Coordinator

Job Title: Care Coordinator – Outpatient SUD
Location: Van Nuys, CA
Department: Outpatient Services
Reports To: Supervisor of Clinical Services
Status: Full-Time | Non-Exempt

Salary: $25/hr to $30/hr DOE

SUMMARY OF POSITION

Reporting to the Supervisor of Clinical Services, the Care Coordinator is responsible for linking patients with appropriate health and social services to address specific needs and achieve treatment goals. This patient-centered role complements clinical services, such as counseling, by addressing social determinants of health that may negatively impact treatment success and overall quality of life. The Care Coordinator ensures that patients receive support to increase self-efficacy, self-advocacy, basic life skills, coping strategies, and self-management of biopsychosocial needs.

DUTIES AND RESPONSIBILITIES

Connection:

• Establish and maintain high-quality referrals and linkages to community resources, including housing, educational, social, prevocational, vocational, rehabilitative, and other services.
• Actively assist patients with applications and maintenance of public benefits (e.g., Medi-Cal, Minor Consent Program, General Relief, and County-funded programs).
• Support patients experiencing homelessness by helping them access the Coordinated Entry System (CES) and completing necessary intake and assessment documentation.
• Develop relationships and protocols with external service providers to ensure patients have actual access to necessary services rather than just providing resource lists.
• Ensure benefits are transferred when patients move across counties.

Coordination:

• Facilitate patient transitions between Substance Use Disorder (SUD) Levels of Care (LOCs), including scheduling assessment appointments and coordinating documentation transfers.
• Coordinate with physical health providers, managed care health plans, community health clinics, and mental health providers to ensure integrated care.
• Work closely with county and state entities such as DPSS, DCFS, Probation, and Housing Providers to align health services with social services.
• Follow up with patients post-hospital discharge, emergency room visits, or transitions from residential care to ensure continuity of care.
• Track referrals until confirmation of patient enrollment in receiving treatment agencies.

Communication:

• Serve as the primary point of contact between SUD care, mental health care, medical care, and social services.
• Communicate patient updates and treatment progress to service providers, county agencies, courts, and other relevant stakeholders.
• Advocate for patient needs with healthcare and social service providers, ensuring that patients receive timely and necessary services.
• Educate patients on their rights and responsibilities related to care access and service coordination.
• Provide required documentation and correspondence, including letters for legal and social service agencies verifying patient participation in SUD treatment.

Special Population Considerations:

• Address the unique needs of special populations, including individuals experiencing homelessness, persons with co-occurring disorders (CODs), pregnant and parenting women (PPW), youth, LGBTQ+ individuals, and those involved with the criminal justice system.
• Advocate for patients in school, court, or correctional settings by preparing necessary reports, letters, and in-person representation.
• Coordinate reentry services for justice-involved individuals, ensuring seamless integration into community services.

Documentation and Compliance:

• Utilize the ASAM CONTINUUM assessment to determine patient needs and develop an individualized care coordination plan.
• Maintain accurate and timely documentation of Care Coordination activities in Progress Notes and Treatment Plans.
• Ensure that care coordination services are provided per county, state, and federal regulations, obtaining necessary Release of Information (ROI) documentation.
• Monitor patient progress and adjust care coordination strategies as needed to align with treatment goals.

EXPERIENCE/QUALIFICATIONS

• Bachelor's degree in social work, psychology, public health, or a related field, preferred (Master’s degree preferred).
• Minimum of 2 years of experience in care coordination, case management, or a related field in behavioral health or social services.
• Knowledge of SUD treatment, mental health care, and social service systems.
• Familiarity with Medi-Cal and other public benefit programs.
• Experience working with vulnerable populations, including individuals experiencing homelessness and justice-involved individuals.
• Strong interpersonal, organizational, and communication skills.
• Ability to work collaboratively with multiple stakeholders, including healthcare providers, government agencies, and community organizations.
• Proficiency in electronic health record (EHR) systems and case documentation.
• Culturally competent approach to patient care, with a commitment to equity and inclusion.
• Ability to work independently and handle multiple priorities effectively.
• Valid driver’s license and reliable transportation may be required.

REQUIREMENTS

• Must pass Department of Justice (DOJ) and Federal Bureau of Investigations (FBI) background clearance.

• Valid California Driver’s license.

• TB clearance.

• Driving record acceptable for coverage by Gateways insurance carrier.

• Fire and Safety Training*.

• First Aid Training Certification*.

• CPR Certification*.

• Crisis Prevention Institute Training (CPI)

• Training in Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBI), ASAM Continuum, Trauma-Informed Care, and Harm Reduction.

• Productivity must meet a minimum of 50%, which includes providing direct billable services 4 out of 8 hours per working day. Care Coordinators will be eligible for incentive compensation according to the policy if productivity exceeds 62.5%, or 5 hours out of every 8 hour day.

PHYSICAL REQUIREMENTS

To perform this job, you must be able to carry out all essential functions successfully. Reasonable accommodation may enable qualified individuals with disabilities to perform the job. Approximately 50% of the time is spent sitting while frequently required to walk, stand, and bend. Occasionally required to stoop, kneel, crouch, or crawl. Employees must lift and/or move unassisted up to 20 pounds.