Client Navigator

Department:

Integrated Services

Positions Supervised:

None

Immediate Supervisor:

Sr. Manager of ISP

Status:

Non-Exempt

JOB SUMMARY:

Provides care coordination services to support timely access to appropriate levels of care. Completes required screenings and risk assessments in alignment with CCBHC standards, including behavioral health, suicide and overdose risk, and social determinants of health (SDOH), to inform service needs and coordination. Facilitates referrals and linkage to internal and external medical, behavioral health, and community-based services, ensuring continuity of care through follow-up, care transitions, and collaboration with interdisciplinary team members and community partners. Identifies and responds to urgent and emergent needs, including coordination of and connection to 24/7 crisis services, to support safety and stabilization.

Ensures all services, documentation, and communication comply with applicable state statutes and rules, CARF standards, and federal regulations including HIPAA and 42 CFR Part 2, as well as organizational policies and procedures. Maintains accurate and timely documentation and represents the organization professionally, promoting its mission while fostering positive relationships with clients, families, referral sources, and community partners.

ESSENTIAL FUNCTIONS

1. Conducts initial intake functions, including completion of required screening tools in alignment with CCBHC standards, such as behavioral health screenings, risk assessments (including suicide and overdose risk), and screening for social determinants of health (SDOH). Gathers demographic and clinical information and facilitates timely and appropriate referral processing. Ensures immediate identification of urgent or emergent needs and initiates appropriate response protocols. 
2. Provides comprehensive care coordination to individuals referred for services, ensuring timely access to care in accordance with CCBHC access standards. Assists individuals in identifying appropriate services and facilitates referrals and linkage to internal and external providers, including medical, behavioral health, and community-based resources. Maintains collaborative relationships with referral sources and community partners. 
3. Screens for and responds to crisis needs, including assessing risk and ensuring individuals have access to 24/7 crisis services as required by CCBHC standards. Facilitates warm handoffs to crisis providers, mobile crisis teams, or higher levels of care as appropriate, and ensures follow-up and care coordination after crisis episodes to support continuity and stabilization. 
4. Functions as an active member of the interdisciplinary treatment team. Participates in staffings and meetings as scheduled, providing input on individual needs, risk factors, and progress. Communicates using person-centered, trauma-informed, culturally responsive, and recovery-oriented approaches. 
5. Assists individuals in identifying strengths, needs, and preferences; supports the development of person-centered goals; and coordinates services to support goal attainment. Provides ongoing monitoring, follow-up, and care transitions to ensure continuity of care, including coordination across levels of care and with external providers. 
6. Maintains accurate, timely, and complete documentation in accordance with organizational policies, CCBHC requirements, CARF standards, and state and federal regulations. Documentation includes, but is not limited to, intake records, screening results, risk assessments, crisis interventions, referrals, care coordination activities, and progress notes. Ensures documentation supports continuity of care and compliance with required timeframes. 
7. Effectively communicates, both verbally and in writing, with individuals, families (as appropriate and authorized), team members, and external agencies to support integrated care and service coordination, while adhering to confidentiality regulations including HIPAA and 42 CFR Part 2. 
8. Demonstrates working knowledge of CCBHC model requirements, including integrated care, whole-person care, 24/7 crisis response, and coordination across systems. 
9. Participates in ongoing training and continuing education, attends all required staff meetings and in-services, and completes a minimum of 10 hours of continuing education annually. 
10. Performs all other duties as assigned.

ORGANIZATIONAL COMPETENCIES:

1.  Accountability – Takes ownership for resolving problems, reaching goals, and serving patients, team, and organization. Accepts responsibility for own behavior. Assures that resources are allocated in accordance with the priorities of the strategic plan. Performs self-quality monitoring in order to develop and execute plans to meet established goals.  
2. Time Management – Maximizes the use of time and resources and effectively prioritizes tasks. Completes paperwork, evaluations, and other required documentation accurately and timely.
3. Teamwork – Works cooperatively and capably with a wide variety of people. Actively promotes teamwork and information sharing within and across departments. Works in a spirit of teamwork and trust and maintains professional boundaries in working with others.
4. Flexibility – Adapts rapidly to changing work demands and priorities.
5. Confidentiality – Complies with all HIPAA and 42 C.F.R. Part 2 regulations relating to privacy, security, and confidentiality. Safeguards confidential information of patients, employees, and business operations
6. Safety – Knows and understands emergency procedures and completes incident reports within 24 hours of event with detailed information.
7. Communication – Consistently uses positive communication skills to promote effective interpersonal relationships. Provides timely and thorough follow-up with internal and external customers. Models professionalism by addressing others with appropriate actions, appearance, and communication. Models and promotes effective written and verbal communication.
8. Customer Service – Supports the organization’s customer service initiative. Strives for service excellence by seeking challenges and turning them into opportunities. Anticipates and meets needs of patients while maintaining appropriate boundaries. Displays a friendly, helpful, and approachable demeanor. Obtains feedback from patients regarding their perceptions of the service provided to them and utilizes this information to improve service delivery.  
9. Respect – Establishes compassionate and supportive rapport with patients. Communicates tactfully and respectfully with patients, coworkers, and others.  
10. Quality Improvement – Assures that information is collected, organized, reported and used to improve the quality of systems and services. Recognizes and appropriately reports to supervisor areas within scope of responsibility that fall outside the quality parameters. Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.  

EDUCATION/TRAINING: Bachelor’s Degree in Human Service or Social Work field or equivalent experience in lieu of a degree is required. One year of experience working in the Mental Health or SUD field is preferred. 

SKILLS: Ability to plan, organize work and identify needed resources for clients and linking clients to resources, record keeping, speaking, writing, marketing and public relations skills and computer and word processing ability and counseling skills for this population.

PHYSICAL DEMANDS: Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking and stooping is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus. 

WORK ENVIRONMENT/JOB LOCATIONS: Involves everyday risks or discomforts, requiring normal safety precautions in an office setting, patient care areas, sub-acute medical care area and personal or company patient transport vehicle. Some outdoor exposure when supervising patients outdoors and in recreation programming. May involve working with the client in the community or in their homes. Care Coordination is provided in Rimrock programs including, but not limited to: Residential/Inpatient, Court Services, Outpatient SUD, VA, Mental Health Services, and PACT. 

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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Employee Date Supervisor Date