Behavior -Care Coordinator SAPTA (Full-Time)

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:

1. 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.
2. 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.
3. Prioritize timely access to services for SAPTA Grant priority populations consistent with grant requirements (including interim services when treatment capacity is unavailable).
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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).
10. 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.
11. Participate in community outreach, education, and prevention activities that promote awareness of SUD prevention, treatment, and recovery resources in the urban AI/AN community.
12. 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.
13. 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.

1. High school diploma or GED required; associate or bachelor’s degree in health, human services, social work, or a related field preferred.
2. 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.
3. Ability to work respectfully with diverse tribal backgrounds and urban AI/AN populations, with demonstrated cultural humility and understanding of historical trauma.
4. Effective communication, interpersonal, and organizational skills, including the ability to manage a caseload, track referrals, and meet documentation and reporting deadlines.
5. 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.

Preferred Qualifications:

1. Community Health Worker, Peer Support Specialist, or care coordination certification.
2. 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.
3. Knowledge of social determinants of health and community resources serving the urban AI/AN population in San Diego County.
4. Experience with electronic health records, referral tracking, and grant data collection or reporting; understanding of Medi-Cal and IHS service documentation.

Working Conditions:

1. May involve indoor and outdoor activities, including participation in ceremonies or gatherings.
2. Occasional travel may be required to provide services at events or satellite locations.
3. May involve contact with smoke, sacred herbs, or ceremonial instruments when supporting cultural activities and gatherings.

Preferred:

1. Experience serving a multinational, multicultural population.
2. Familiarity with Community Health Clinics and/or Indian Health Clinics.
3. Bilingual in Spanish/English a plus.

Special Conditions of Employment:

1. Maintains a valid driver’s license, clean driving record, and current auto insurance in accordance with state requirements.
2. Possesses reliable and insured transportation suitable for work-related travel as needed.
3. 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.
4. Annual Background Checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
5. 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.
6. 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.
7. Grant-Funded Position: This position is funded in whole or in part by federal grant funds, including the SAMHSA Substance Abuse Prevention and Treatment (SAPT) Block Grant. Continued employment in this position is contingent upon the availability of grant funding, and this position will end upon the expiration, termination, or non-renewal of grant funding, unless alternative funding is identified and approved by SDCHC.
8. 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.

Knowledge, Skills, and Abilities:

1. Excellent oral and written communication skills.
2. Excellent time management skills
3. Excellent organizational skills and attention to detail.
4. Able to communicate professionally in person and in writing
5. Ability to maintain confidentiality and meticulous records.
6. Effective interpersonal skills.
7. Able to deal effectively with a diversity of individuals.
8. Ability to establish and maintain cooperative working relationships with all during work.
9. Must be reliable and trustworthy.
10. Proficiency in Microsoft Suite or related programs.

Physical and Mental Requirements:

1. Able to lift/move up to 40 pounds, move from place to place.
2. Able to sit at a desk and work on a computer for prolonged periods.
3. Able to stand, bend and reach for prolonged periods.
4. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
5. Ability to supervise, multitask, understand, and follow instructions.
6. Ability to proficiently read, write, speak, and understand English.

Customer Service:

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDCHC.
2. Provides excellent internal and external customer service.
3. Demonstrates SDCHC’s Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participate in ongoing customer service training.
5. Every action seeks to promote SDCHC as a top service organization.

Quality Management:

1. Contribute to the organization's success by participating in quality improvement activities.
2. Complies with all SDCHC policies and procedures and proactively participates in implementing new initiatives.
3. Participate and ensure continuous quality improvement process as directed by clinic leadership.  

Safety:

1. Ensures regulatory compliance and adherence to policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.  
4. Uses all appropriate equipment and/or tools to ensure workplace safety. 
5. Immediately reports unsafe working conditions. 

Privacy/Compliance:

1. Maintains privacy and security of all patients, employees, and volunteers' information and access to such information. Such information is accessed on a need-to-know basis for business purposes only. 
2. Complies with 42 CFR Part 2 requirements governing the confidentiality and disclosure of substance use disorder patient records, including consent requirements for disclosures made for care coordination purposes.
3. Compliance with all regulations regarding corporate integrity and security obligations. Reports on unethical, fraudulent, or unlawful behavior or activity.
4. Upholds strict ethical standards.

Flexibility:

Available for all shifts and, when required, can work evenings and weekends.

Disclaimer:

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.  This description reflects management’s assignment of essential functions.  It does not prescribe or restrict the tasks that may be assigned.  This job description is subject to change at any time.

Preference is given to qualified American Indian/Alaskan Natives under the American Indian Preference Act (Title 25, U.S. Code Section 472, 473, and 473a). Besides the above, the San Diego Community Health Center is an equal-opportunity employer.

Acknowledgement:

San Diego Community Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability, or any other protected class, political affiliation, or belief.

Preference is given to qualified American Indian/Alaskan Natives in accordance with the American Indian Preference Act (Title 25, U.S. Code Section 472, 473 and 473a). In other than the above, the San Diego American Indian Health Center, is an equal opportunity employer.

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.