Behavior -Care Coordinator SAPTA (Full-Time)

San Diego American Indian Health Center•San Diego, CA

19h•$29 - $35•Onsite

About The Position

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.

Requirements

High school diploma or GED required
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.
Maintains a valid driver’s license, clean driving record, and current auto insurance in accordance with state requirements.
Possesses reliable and insured transportation suitable for work-related travel as needed.
CPR/BLS Certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment; online-only certifications are not accepted.
Annual Background Checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by SDCHC, including HIPAA and 42 CFR Part 2 confidentiality training.
Time and Effort Reporting: Maintain accurate time and effort documentation consistent with 2 CFR 200.430, including allocation of time between grant-allowable activities and activities that must be supported by non-federal funds.
Excellent oral and written communication skills.
Excellent time management skills
Excellent organizational skills and attention to detail.
Able to communicate professionally in person and in writing
Ability to maintain confidentiality and meticulous records.
Effective interpersonal skills.
Able to deal effectively with a diversity of individuals.
Ability to establish and maintain cooperative working relationships with all during work.
Must be reliable and trustworthy.
Proficiency in Microsoft Suite or related programs.
Able to lift/move up to 40 pounds, move from place to place.
Able to sit at a desk and work on a computer for prolonged periods.
Able to stand, bend and reach for prolonged periods.
Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
Ability to supervise, multitask, understand, and follow instructions.
Ability to proficiently read, write, speak, and understand English.

Nice To Haves

Associate or bachelor’s degree in health, human services, social work, or a related field preferred.
Community Health Worker, Peer Support Specialist, or care coordination certification.
Experience with SUD systems of care, including ASAM levels of care, Drug Medi-Cal Organized Delivery System (DMC-ODS), withdrawal management, and MAT/MOUD services.
Knowledge of social determinants of health and community resources serving the urban AI/AN population in San Diego County.
Experience with electronic health records, referral tracking, and grant data collection or reporting; understanding of Medi-Cal and IHS service documentation.
Experience serving a multinational, multicultural population.
Familiarity with Community Health Clinics and/or Indian Health Clinics.
Bilingual in Spanish/English a plus.

Responsibilities

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