Job Details: Level: Experienced, Job Location: Sonoma - Santa Rosa, CA, Position Type: Full Time, Salary Range: $28.00 - $30.00Hourly, 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.  We are hiring a new Short-Term Post Hospitalization (STPH) Navigator to provide direct, client-centered wrap-around case management support to individuals transitioning from higher levels of care (e.g., hospital, detox, incarceration, residential treatment, crisis services) into community-based services. As the Navigator, you will play a key role in delivering Community Supports (CS) and Enhanced Care Management (ECM) services by assisting clients in accessing care, coordinating services, and reducing barriers to housing stability and recovery.  Under the direction of the Navigation Manager, you will support a closed-loop referral process, ensuring that referrals to housing, behavioral health, medical, and social services are completed and tracked. This role requires strong attention to documentation standards and Partnership Health Care Medi-Cal service requirements, ensuring that all services are accurately recorded to support program compliance, billing, and quality outcomes. RESPONSIBILITIES: Client Navigation and Care Coordination 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.   Housing Support & Stability 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   Documentation, Billing Support & Compliance 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.   Closed Loop Referrals & Service Tracking 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.   Client Engagement & Support  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.    Care Team Collaboration  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.    Outreach & Community Connections 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.   : Education and Experience  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 community-based services   Lived experience strongly preferred    Professional Skills  Proficiency with Microsoft Word, Excel, Google Workspace, EHR systems, and office technology.  Understanding of community resources and behavioral health systems   Ability to navigate complex service systems   Excellent verbal and written communication and engagement skills   Strong organizational and time management skills   Ability to work independently and within a team   Cultural competence and ability to serve diverse populations   Experience with Electronic Health Records (EHR) preferred   Timely documentation  Flexibility to work occasional evenings or non-standard hours.  Compliance with program and payer requirements    Additional Requirements  Valid California Driver’s License and insurable driving record   Access to a personal vehicle (mileage reimbursed)   Ability to pass LiveScan background check   First Aid/CPR certification may be required    PHYSICAL REQUIREMENTS  Ability to sit, stand, walk, and drive for extended periods   Occasional lifting up to 25 pounds   Frequent computer use and documentation   Ability to travel within Sonoma and Marin Counties   We are an Equal Opportunity Employer committed to creating a workplace that celebrates diversity, promotes equality, and fosters inclusion. We encourage applications from individuals of all backgrounds, experiences, and perspectives.