MAT Patient Navigator / Case Manager

POSITION TITLE: MAT Patient Navigator / Case Manager

DEPARTMENT: Quality Improvement Q.I.

REPORTS TO: CMO or BH Director

POSITION OVERVIEW:  

The Patient Navigator will work closely with FHCCGLA’s C.M.O. and healthcare teams to improve coordination of patient care.  The Patient Navigator will assist FHCCGLA patients by identifying their needs as per FHCCGLA’s Quality Improvement (Q.I./Q.A.) and HEDIS goals.

The Recovery Specialist provides comprehensive support to participants in the Substance Use Disorder (SUD) and Medication‑Assisted Treatment (MAT) programs, working collaboratively with SUD Counselors and clinical staff. This includes participant screening, documentation, facilitating groups (within scope), supporting appointment scheduling and transportation, onboarding new participants, and engaging with participants daily in their recovery process.

KEY PRIORITY:

1. Conduct outreach to external agencies, including residential rehabs, shelters, jails, schools, and churches, to educate them about MAT services and connect potential patients to the clinic
2. Establish and maintain partnerships with community organizations to strengthen referral pathways
3. Ensure patients complete all required labs and urine drug tests prior to scheduled MAT visits
4. Coordinate and schedule all necessary follow-up appointments as directed by the clinician
5. Maintain contact with patients to ensure attendance at scheduled appointments; assist with transportation arrangements as needed
6. Coordinate closely with the pharmacy to ensure patients receive their medication in a timely manner
7. Support the expansion of MAT services, including facilitating a half-day MAT clinic at each site monthly, once provider training is completed
8. Assist in arranging education and training for providrs and staff through expert-let sessions, with the goal of fostering a supportive, stigma-free environment for patients with SUD; and
9. Represent FHCCGLA at community events and regional health fairs to promote MAT services and increase program visibility

DUTIES/RESPONSIBILITIES:

1. Greet all clients, visitors, and other contacts from the general public.
2. Conducts brief conversations with patient and family member(s) as applicable to provide instructions or health education information (e.g., fecal occult instructions, etc.) as needed.
3. Patient navigator will pull GAP Reports, i2i Tracks System, and NextGen Reports to determine which patients are due for various preventive care health maintenance measures and follow-up.
4. Makes contact attempts to patients as directed following FHCCGLA’s Q.I./Q.A. & HEDIS goals and objectives.
5. Assists clients from diverse cultural backgrounds in understanding the health system in terms of, access or limits to services.
6. Maintains communication with FHCCGLA providers both verbally or by setting up communication flags through the E.H.R.
7. Undertakes continuous self-improvement, attending applicable training, seminars, in-services, and educational classes to maintain skills competency and current knowledge for standard of care and effective practices.
8. Responsible for following all agency safety and health standards, regulations, procedures, policies, and practices.
9. Identifies, initiates, and implements measures to deliver high quality care to patients and improve services.
10. Responds efficiently and timely to all patient and provider staff needs and inquiries.
11. Ensures excellent customer service to all FHCCGLA patients.
12. Works with the operations managers to manage patient scheduling and flow to address bottlenecks, scheduling issues, etc.
13. Handles patient grievances according to FHCCGLA’s Policy & Procedure.
14. Assists in developing, updates & reviews of FHCCGLA Policies & Procedures (P&P’s) as needed (with input from all other key personnel).
15. Ensures HIPAA compliance by maintaining strict confidentiality of all patient data and E.H.R./Practice Management System (PMS) according to regulations and FHCCGLA’s P&P’s.
16. Attends the following meetings/trainings:
    1. Mandatory Quarterly Staff Meeting/Trainings- Quarterly (Jan., Apr., Jul. & Oct.)
    2. Corporate Risk Management Meeting- Quarterly (Jan., Apr., Jul. & Oct.), as needed (advanced notice will be provided when feasible)
    3. Clinical & Operations (C&O) Meeting- As needed (advanced notice will be provided when feasible)
    4. Meetings with FHCCGLA’s Executive Leadership, as needed (advanced notice will be provided when feasible)
17. Other pertinent meetings- As scheduled
18. Remains informed of:
    1. Current legal and regulatory changes related to scope of practice.
    2. Specific programs/payors, insurances accepted, and services being offered at FHCCGLA.
    3. All applicable Policies & Procedures.
19. Shall serve as a liaison between clients and medical staff.
20. Facilitates the flow of information regarding updates and changes from front and back office staff as necessary.
21. Assist clients with completion of forms.
22. Provides information on services offered on site.
23. Shall assist as an EyePACS Photographer.
    1. Responsible to ensure that all FHCCGLA diabetic patients are being scheduled for an EyePACS retinal photography appointment (create Memo’s, send emails, etc. as reminders to FHCCGLA providers/staff to schedule their patients for an appointment).
    2. Shall take “capture” and upload digital images of diabetic patient’s retina through the use of the U.C. Berkley provided photography equipment.
    3. Shall follow-up with all no-shows.
    4. Shall use the “store and forward” electronic consult technology: digital images that are taken and forward to the EyePACS website.
    5. Shall forward electronically all digital images taken of all diabetic patients retina to a trained U.C. Berkley provider for interpretation.
    6. Shall ensure to meet U.C. Berkley’s requirement of 30 retinal photographs per month. If unable to meet the required # will notify supervisor and develop a plan by mid-month in efforts to reach goal.
24. Educate clients regarding available benefits (health coverage programs) and will refer directly to FHCCGLA outreach & enrollment specialists for eligibility screening and/or application assistance.
25. Represents the clinic in all matters dealing with the delivery of health care services and works closely with the Chief Medical Officer.
26. Works closely with the outreach team in greeting/receiving new clients and assisting with the intake process.
27. Required to attend meetings as scheduled (e.g., Q.I./Q.A., Quarterly Staff Meeting/Training, Medical Advisory Committee Meeting, etc.).
28. All other tasks as assigned.

1. Answer incoming calls and engage prospective participants, providing referrals as needed.
2. Conduct participant screening interviews and documentation in the chart
3. Facilitate medication observation as applicable and complete all required documentation.
4. Engage daily with participants: establish rapport, encourage involvement in recovery communities (e.g., 12‑step groups), arrange transportation as needed, and support acclimation to program.
5. Facilitate interactive group sessions (within scope of practice), document attendance and individual participation.
6. Support participants in life‑skills development: personal hygiene, room/bathroom upkeep, meal planning, household shopping, managing chores, and compliance with program expectations.
7. Conduct outreach to external agencies (residential rehab programs, shelters, jails, schools, faith‑based organizations) to educate about MAT services and strengthen referral pathways.
8. Coordinate with MAT/clinical team: ensure participants complete required labs and urine drug tests before scheduled visits, schedule follow‑up appointments, track medication access in coordination with pharmacy.
9. Represent the organization in community events and regional health‑fairs to promote MAT/SUD services and increase program visibility.
10. Participate in all assigned staff meetings, trainings, and development activities, including quarterly staff meetings.
11. Other duties as assigned.

Preferred Qualifications:

1. Previous experience working in SUD/MAT settings, peer‑recovery support, or behavioral health care.
2. Experience with group facilitation and life‑skills coaching.
3. Knowledge of local community resources, recovery supports, and referral networks.
4. Experience coordinating transportation/logistics for participants.
5. Experience promoting programs and representing an organization in community settings.

MINIMUM QUALIFICATIONS:

1. High school diploma, minimum (or GED equivalent).
2. FQHC experience, highly preferred.
3. Excellent analytical skills.
4. Motivation to take initiative to ensure all tasks performed are completed thoroughly and accurately.
5. Excellent writing and verbal communication skills.
6. Knowledge of administrative principles and procedures.

7. Computer knowledge preferred (e.g., NextGen (E.H.R. & PMS), Microsoft Word and Excel).

1. Ability to speak Spanish, required.
2. Experience working with clients and staff from diverse socio-economic, ethnic and cultural backgrounds, preferred.
3. Strong interpersonal and problem-solving skills, to include persuasiveness, assertiveness, initiative and sensitivity when dealing with patients as well as agency staff.
4. Ability to take initiative in performing and completing tasks.
5. Ability to prioritize workload and work under pressure of deadlines.
6. Willingness to adapt to changes in clinic schedules, agency growth and expansion.
7. Ability to function self-sufficiently, requiring little supervision.
8. Commitment to the mission & vision of Family Health Care Centers of Greater Los Angeles, Inc.
9. Medical Assistant experience, preferred.
10. Transportation required. Will need to travel to FHCCGLA clinic sites as necessary.
11. Evenings and weekends may be required.
12. Current California Driver License.

1. Peer Support Specialist Certification (or equivalent credential) preferred but not required. A prior lived experience in recovery is preferred but not required.
2. Prior clinical or case management experience/ MA/ LVN are encouraged to apply.
3. Minimum one year of sustained sobriety (if the candidate is in recovery).
4. Excellent interpersonal and communication skills; ability to build trust and rapport with participants, many of whom have SUD and/or co‑occurring disorders.
5. Ability to facilitate groups and support peer‑based recovery activities.
6. Strong organizational skills; competency in documentation and use of electronic health records (EHRs).
7. Proficient in Microsoft Office (Word, Excel, Outlook).
8. Valid U.S. driver’s license with a clean DMV record and ability to provide transportation as required.
9. Willingness to undergo pre‑screen drug and TB testing, and submit to background check.
10. Comfort working in a zero‑tolerance drug‑and‑alcohol workplace environment.
11. Ability to engage in outreach and community partnership development.
12. Ability to support MAT operations: coordinate labs, urine drug testing, pharmacy interactions, and scheduled follow‑ups.

Working Conditions/Physical Requirements:

1. Must be able to travel between clinic sites and community locations as needed (for outreach, transportation of participants).
2. May be required to work occasional evenings or weekends depending on program needs (e.g., community events, half‑day MAT clinics).
3. Ability to manage tasks in a fast‑paced, multi‑discipline team environment at a Federally Qualified Health Center with multiple sites.
4. The role involves direct contact with participants in various stages of recovery and may include crisis‑intervention or de‑escalation scenarios.

ADDITIONAL ELIGIBILITY QUALIFICATIONS:

1. Ability to work well with others in a professional and team-oriented environment.

1. Well-developed interpersonal skills, friendly personality and able to motivate staff by promoting teamwork.
2. Ability to relate to the public regardless of ethnic, religion and economic status.

4. Excellent communication skills.
5. Willingness to travel.

1. Strong planning and organizational skills.
2. Problem analysis and critical thinking skills.
3. Excellent customer service skills.
4. Knowledge of the following (but not limited to), preferred:

PPO’s                              HMO’s

Medicare                         Family PACT                  CPSP         

Medi-Cal                         Fee-for-Service              

                            Managed Care Plans       Every Woman Counts