Care Navigator Crisis & 24/7

The Care Navigator for Crisis & 24 Hour is responsible for coordinating client movement from initial contact at the Triage Center through residential admission, outpatient linkage, and ongoing engagement. This role will be primarily assigned to a Crisis & 24 Hour Restart Team, with a focus on individuals with substance use disorders and housing instability, ensuring rapid connection to care and continuity across all service levels. Core Responsibilities Initial Engagement Coordinate with Crisis Services Triage Center clinicians when clients present who are not currently receiving services Review newly created client charts and assist in identifying appropriate level of care Support identification of clients appropriate for Addiction Recovery Center (ARC) or outpatient services Initiate communication with Restart Team members (SDP and Peer) upon assignment Treatment Coordination Facilitate assignment of SDP (primary) and Peer (secondary) to client treatment team Send and track internal communication, including anticipated ARC admission date/time Ensure Restart Team meets with client within 1 business day Support completion of intake paperwork prior to ARC admission Coordinate with ARC admissions staff regarding bed availability If admission is delayed beyond 72 hours, assist in redirecting client to outpatient pathway Track client progress and anticipated discharge timelines Support weekly coordination between Restart Team and ARC Case Managers Assist with development of housing and transition plans Coordinate with Outreach teams to support housing identification and community-based engagement Identify and escalate barriers to discharge Work with embedded representatives from Managed Care Organizations to identify available resources for qualifying members Collaborate with members of Housing and Employment services to coordinate and facilitate completion of necessary paperwork to access available services. Outpatient Referral & Linkage Coordinate outpatient referrals for clients not admitted to residential Ensure intake appointments are scheduled within 1 business day Assist clients with: Medicaid applications Required documentation and assessments ApexCare App setup and navigation Arrange transportation to intake and follow-up appointments Ensure proper assignment within the Restart Team care pathway Assist in scheduling and facilitating strong warm handoff processes between ARC level of care and outpatient, including initial multidisciplinary treatment staffing for Restart Team pathway clinicians. Ongoing Engagement & Resource Coordination Support clients in accessing: Housing Transportation Food resources Identification and benefits Medical care and employment resources Participate in multidisciplinary huddles with: Restart Team Outreach Embedded community partners (e.g., Salvation Army team) Outpatient Clinical Teams ARC Care Managers Disengagement & Re-engagement Monitor attendance and initiate outreach following missed appointments Follow Restart Team disengagement protocol: Immediate team notification 3-day outreach attempts Escalation to team huddle Engagement letter Coordinate rapid re-engagement and rescheduling when contact is reestablished Notify members of the wider treatment continuum of client disengagement to initiate intensive re-engagement efforts. Documentation & Tracking Maintain accurate documentation of all coordination and outreach efforts Track client movement across levels of care and engagement status Ensure that members of the Restart Team is within GRAND compliance standards of completeness and timeliness Monitor the consistent and accurate completion of the Care Coordination Care Pathway for all clients in the Restart Team Pathway Other reasonably assigned tasks as assigned by the Executive Director of Crisis and 24-Hour Transition Care Experience and Requirements Certified Case Manager II (CMII) required Experience in behavioral health, substance use treatment, crisis services, or community-based work preferred Ability to work in a fast-paced, high-acuity environment Strong communication and organizational skills including directing in a non-supervisory role a heavily case management focused- team Strong sense of accountability and follow-through Ability to engage clients in the community Strong knowledge of care coordination principles and their importance within the CCHBC model Working knowledge of healthcare documentation and completeness of required forms to facilitate care coordination, including discharge summaries and releases of information. Basic knowledge of available community resources, with ability to expand working knowledge to assist client in resource acquisition. Key Performance Indicators Timely coordination and engagement of clients referred through the Triage Center > 80% successful facilitation of ARC residential admissions and outpatient linkage services > 70% of clients discharged with documented transition, housing, or community support planning > 85% completion of follow-up and re-engagement efforts for clients who disengage from services >90% compliance with documentation, care coordination, and pathway tracking standards Participation in multidisciplinary coordination and continuity of care activities > 75% successful client movement between crisis, residential, outpatient, and community-based services without loss of follow-up care