Complex Care Recovery Navigator

Salary Range: $65,000 - $78,000 / year

The Complex Care Recovery Navigator is a specialized, central member of the multidisciplinary primary and behavioral health integration team, responsible for managing the full patient journey: from initial outreach and enrollment through active care coordination, stabilization, and program graduation for individuals with substance use disorders (SUD), alcohol use disorders (AUD), and co-occurring mental health conditions.

The Navigator serves as the primary point of contact for triage, program enrollment, care coordination, and external liaison activities with local and state partners, including BHS, Brien, drug court, DCF, and probation. This role owns end-to-end case management for an assigned cohort of high-acuity patients, leads efforts to address social determinants of health, reduce barriers to care, decrease preventable emergency department utilization, and sustain engagement throughout the recovery continuum within an integrated care grant.

The position requires demonstrated expertise combining clinical knowledge, systems navigation, and professional or lived experience with the populations served. It is not structured as an entry-level role.

Essential Duties and Responsibilities

1. Program Enrollment and Patient Outreach

Lead the front end of the patient journey by identifying, engaging, and enrolling referred patients into the program:

• Triage and conduct initial outreach to referred patients to describe available services and invite enrollment.
• Explain program benefits, expectations, and patient rights, including confidentiality protections under 42 CFR Part 2.
• Assess patient interest and readiness to engage in integrated care services.
• Initiate enrollment and obtain all necessary consents and releases of information.
• Track outreach attempts and document patient responses in the program tracker.
• Provide timely, professional communication to internal and external referring teams.

2. Patient Engagement and Care Coordination

Serve as the primary point of contact for enrolled patients across the full spectrum of acuity, maintaining continuity of engagement from stabilization through long-term recovery.

Active Care Coordination

• Schedule and coordinate appointments across the integrated care team, behavioral health referral providers, and other necessary services.
• Manage removal of barriers to care (e.g., ensure patients have active phones with minutes for appointment reminders and transportation to and from appointments).
• Monitor attendance, follow up on missed appointments, and ensure continuity of care during transitions between levels of care or service settings.
• Track patient touches and counseling sessions to ensure alignment with individualized care plans.

In-Person Connections

• Monitor health center schedules to identify when enrolled patients have appointments on-site.
• Conduct warm handoffs and brief check-ins during patient visits, addressing immediate needs and facilitating real-time connections with medical providers, therapists, and peer support staff.

Ongoing Outreach

• Conduct monthly outreach calls to stable, lower-acuity patients to maintain connection outside of active clinical touchpoints.
• Assess for emerging needs, changes in status, or barriers to recovery during check-ins.
• Identify patients requiring increased clinical services and escalate to appropriate team members.

3. Recovery Resources and Social Determinants of Health

Screen for and address the full range of clinical and structural barriers to recovery by connecting patients to recovery services and community resources that support long-term stability.

Recovery Services

• Connect patients with outside counseling, psychiatric providers, and mutual aid groups such as AA, NA, and other recovery programming.
• Facilitate access to recovery community centers, recovery-oriented activities, residential treatment, and intensive outpatient programs as needed.
• Maintain an updated resource directory of recovery services, meeting schedules, and community supports.

Social Determinants of Health

• Conduct comprehensive SDOH assessments covering housing, food security, transportation, employment, education, legal issues, and financial needs.
• Develop and implement individualized action plans to address identified barriers.
• Assist with benefits applications including Medicaid, SNAP, disability, and housing vouchers in partnership with the ACO Team.
• Monitor and follow up on referrals to ensure patients successfully access needed resources.

Patient Supplies

• Track food and clothing provisions, reorder when supplies are low, and organize inventory for efficient access.
• Recommend additional supply categories based on patient feedback to ensure the program continues meeting evolving needs.

4. External Agency and Legal System Liaison

Coordinate patient care across external systems, including public safety and child welfare partners.

• Serve as primary point of contact for drug court, Department of Children and Families (DCF), probation, and parole regarding shared patients.
• Facilitate communication between team clinicians and external agencies; provide progress updates and documentation in compliance with releases of information.
• Align care plans with requirements from drug court, probation, or DCF involvement.
• Ensure all external communication complies with 42 CFR Part 2 confidentiality regulations.

5. Confidentiality and Release of Information Management

• Obtain, track, and maintain all necessary consents and releases of information in accordance with 42 CFR Part 2.
• Monitor expiration dates and secure renewals; ensure scanned ROI documentation is current in each patient's EMR.
• Educate patients about their confidentiality rights under federal substance use disorder regulations.
• Support team-wide compliance with 42 CFR Part 2 requirements.

6. Emergency Department Utilization Reduction

• Provide support to the Crisis Intervention Lead as needed.
• Coordinate with emergency departments to facilitate appropriate follow-up care after ED visits.
• Track and analyze ED utilization patterns for assigned patients to inform care planning and program strategy.

7. Program Completion and Graduation

Close the patient journey by transitioning patients out of active program services while preserving long-term recovery supports.

• Identify patients meeting program completion criteria and collaborate with the multidisciplinary team to develop graduation plans.
• Coordinate graduation ceremonies and recognition to mark patient achievements.
• Ensure graduates understand re-engagement pathways and have information on ongoing recovery supports.
• Maintain periodic check-ins with graduates to support outcome tracking and program sustainability.

8. Documentation, Tracking, and Team Collaboration

• Maintain accurate, timely documentation in the EHR, including all patient contacts, outreach attempts, appointments, referrals, warm connections, interventions, and service utilization.
• Track patient touches, counseling sessions, and interventions to monitor care plan adherence.
• Participate in weekly multidisciplinary team meetings, present case updates, and contribute to problem-solving on complex patients.
• Communicate regularly with the Project Manager regarding caseload, outcomes, and program needs; collaborate closely with the Crisis Intervention Lead on high-risk patients.
• Contribute to quality improvement and program evaluation; track and report outcomes including enrollment, engagement metrics, ED utilization, and recovery milestones.

Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience:

• Bachelor’s degree in social work, psychology, counseling, public health, nursing, or a related field preferred.
• Minimum two years’ experience in case management with individuals with substance use disorders and/or mental illness.
• Experience addressing social determinants of health and connecting patients to community resources.
• Experience working with criminal justice-involved populations and understanding of drug court, probation, and parole systems preferred.
• Experience working with underserved or vulnerable populations in community health settings.
• Experience in integrated or collaborative care models preferred.
• Knowledge of 42 CFR Part 2 confidentiality regulations preferred, or willingness to learn.
• Lived experience with recovery is valued but not required.

Knowledge, Skills, and Abilities:

• Strong understanding of substance use disorders, recovery principles, harm reduction approaches, and medication-assisted treatment.
• Comprehensive knowledge of co-occurring mental health and substance use disorders and integrated behavioral health and primary care models.
• Understanding of 42 CFR Part 2 and other confidentiality requirements for substance use disorder treatment.
• Comprehensive knowledge of social determinants of health, community resources, public benefits systems, and social services.
• Understanding of criminal justice systems, drug courts, probation, and child welfare systems.
• Excellent interpersonal and communication skills with the ability to build therapeutic relationships.
• Strong organizational skills and ability to manage a complex caseload with detailed tracking systems.
• Meticulous attention to detail for documentation and compliance requirements.
• Proficiency with electronic health records, care coordination platforms, and data tracking systems.
• Ability to work collaboratively within a multidisciplinary team and with external agencies while requiring minimal supervision.
• Cultural humility and ability to work effectively with diverse populations.
• Non-judgmental, patient-centered, trauma-informed approach to care.
• Crisis intervention, de-escalation, and strong problem-solving skills.
• Demonstrated experience navigating complex systems and advocating within them.
• Demonstrated ability to maintain professional boundaries.

Licensure and Certification:

• Valid state driver’s license and reliable transportation required.
• CPR/First Aid certification, or willingness to obtain within 30 days.
• Naloxone administration training, or willingness to obtain within 30 days.

Working Conditions:

• Primarily office-based work in an outpatient primary care setting during standard clinic hours, with some flexibility.
• Occasional home visits accompanied by other team members.
• Occasional attendance at court hearings or external agency meetings.
• Exposure to patients in various stages of recovery, including active substance use.
• May encounter emotionally challenging situations and complex psychosocial stressors.

Compensation details: 65000-78000 Yearly Salary

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