SUD Care Coordinator - MSW/MFT/LPC

Title of Position: SUD Care Coordinator

Location: Gateways Substance Use Disorder Programs

Exempt/Non-Exempt: Non-Exempt

Union/ Non-Union: Union

Supervisor: Program Director

Gateways Hospital and Mental Health Center's Outpatient Healing and Addiction Recovery program is a newly certified program. Candidates will have the opportunity to be a part of an exciting start up phase that will include outreach and engagement of new clients, establishing community partnerships with other county providers and participating in program development. We are looking for highly motivated, energetic and qualified individuals who can help us establish our new program and bring much needed services to a vulnerable population of clients in our community. We invite you to consider joining our team and be a part of an exciting phase of expansion and growth for Gateways Hospital and Mental Health Center!

Summary Of Position Reporting to the Program Supervisor, the Care Coordinator is responsible for linking patients with appropriate health and social services to address specific needs and achieve treatment goals. This patient-centered role complements clinical services, such as counseling, by addressing social determinants of health that may negatively impact treatment success and overall quality of life. The Care Coordinator ensures that patients receive support to increase self-efficacy, self-advocacy, basic life skills, coping strategies, and self-management of biopsychosocial needs.

Essential Duties Connection

• Establish and maintain high-quality referrals and linkages to community resources, including housing, educational, social, prevocational, vocational, rehabilitative, and other services.
• Actively assist patients with applications and maintenance of public benefits (e.g., Medi-Cal, Minor Consent Program, General Relief, and County-funded programs).
• Support patients experiencing homelessness by helping them access the Coordinated Entry System (CES) and completing necessary intake and assessment documentation.
• Develop relationships and protocols with external service providers to ensure patients have actual access to necessary services rather than just providing resource lists.
• Ensure benefits are transferred when patients move across counties.

Coordination

• Facilitate patient transitions between Substance Use Disorder (SUD) Levels of Care (LOCs), including scheduling assessment appointments and coordinating documentation transfers.
• Coordinate with physical health providers, managed care health plans, community health clinics, and mental health providers to ensure integrated care.
• Work closely with county and state entities such as DPSS, DCFS, Probation, and Housing Providers to align health services with social services.
• Follow up with patients post-hospital discharge, emergency room visits, or transitions from residential care to ensure continuity of care.
• Track referrals until confirmation of patient enrollment in receiving treatment agencies.

Communication

• Serve as the primary point of contact between SUD care, mental health care, medical care, and social services.
• Communicate patient updates and treatment progress to service providers, county agencies, courts, and other relevant stakeholders.
• Advocate for patient needs with healthcare and social service providers, ensuring that patients receive timely and necessary services.
• Educate patients on their rights and responsibilities related to care access and service coordination.
• Provide required documentation and correspondence, including letters for legal and social service agencies verifying patient participation in SUD treatment.

Special Population Considerations

• Address the unique needs of special populations, including individuals experiencing homelessness, persons with co-occurring disorders (CODs), pregnant and parenting women (PPW), youth, LGBTQ+ individuals, and those involved with the criminal justice system.
• Advocate for patients in school, court, or correctional settings by preparing necessary reports, letters, and in-person representation.
• Coordinate reentry services for justice-involved individuals, ensuring seamless integration into community services.

Documentation and Compliance

• Utilize the ASAM CONTINUUM or SAPC Youth ASAM assessment to determine patient needs and develop an individualized care coordination plan.
• Maintain accurate and timely documentation, per regulatory agency and Gateways’ requirements, of Care Coordination activities in Progress Notes and Treatment Plans.
• Ensure that care coordination services are provided per county, state, and federal regulations, obtaining necessary Release of Information (ROI) documentation.
• Monitor patient progress and adjust care coordination strategies as needed to align with treatment goals.
• Perform other duties as assigned.