Short-Term Post Hospitalization Navigator

Job Details Level: Experienced

Job Location:

Sonoma - Santa Rosa, CA 95407

Position Type:
Full Time Salary Range: $28.00 - $30.00 Hourly

Travel Percentage :
Up to 25%

Job Shift: Day Job Category:
Health Care 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.

• 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.

• 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

• 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.

• 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.

• 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.

• 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…