Care Support Coordinator

Job Overview

The Care Support Coordinator is responsible for providing patient centered care to patients presenting with complex psycho-social barriers to care. The Care Support Coordinator works collaboratively with medical providers and mental health clinicians to develop and implement care plans, ensure patient follow-through to specialty care appointments, and connect patients to external resources. The Care Support Coordinator plays an integral role in the mental health team, participating in group meetings and providing logistical support. Patient care will include accompaniments to specialty care appointments which will require solitary field work and engagement with external systems. Interventions will include psychosocial assessments and appropriate internal/external referrals; and will include crisis intervention, de-escalation, and brief behavioral interventions

The Care Support Coordinator is expected to maintain a high degree of professional competence and the highest possible ethical standards, and to function as part of a care-giving team. As is true of all Lyon-Martin Health Services staff and volunteers, the Care Support Coordinator is also responsible to uphold and imbue in others a commitment to addressing racism, and gender and sexual discrimination within the organization and our clinical practice.

The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

Key Responsibilities

  • Participate as a member of the Care Support Team to provide support and assistance to individuals with complex medical and/or mental health needs. Participate in case conference meetings with the interdisciplinary team to develop and implement a care plan to address patients’ identified goals.
  • Make referrals to external services including Intensive Case Management, Paratransit, IHSS, domestic violence resources, General Assistance, Short-term Disability Income, CalFresh, and Project Open Hand. Assist clients in filling out legal name and gender marker change paperwork, as well as navigating this process.
  • Accompany patients to medical appointments as requested by patients and/or Primary Care Provider. Coordinate care with collateral supports to improve stability with psychosocial, mental health and/or medical concerns. This includes patient’s case managers, therapists, hospital discharge planners, housing staff, etc. Work with patients to strengthen both formal (caseworkers, support groups, other professionals) and informal (friends, family) support systems in order to work toward termination from the Care Support Program.
  • Participate in weekly group supervision meetings with the mental health team. Meet with clients interested in engaging in therapy services through “warm handoffs” to gauge client’s needs and connect to our in-clinic therapists. Follow up with clients as needed to schedule them for therapy intakes.
  • Other duties, as assigned

Education and Knowledge, Skills and Abilities

Education and Experience

  • Bachelors in Social Sciences field preferred

Background Clearance

  • Must not be on active parole or probation


  • Anti-racism framework and commitment.
  • Experience working successfully with issues of substance abuse, mental health, criminal background, and other potential barriers to economic self-sufficiency.
  • Experience working with populations with varying lifestyles, ages, sexual orientations, ethnic and cultural backgrounds and economic status.
  • Strong proficiency with Microsoft Office applications, specifically Word Outlook and internet applications
  • Experience working with lesbian, bisexual and transgender patients, preferred.
  • Experience with biopsychosocial assessments; direct patient care experience, preferred.
  • Experience working with homeless, mentally ill, HIV+, substance using, and formerly incarcerated patients, preferred.
  • Experience working in a medical setting, preferred.

Skills and Abilities

  • Ability to work cooperatively and effectively as part of interdisciplinary team.
  • Able to communicate well at all levels of the organization including working with organization leadership and high-level representatives of partner organizations.
  • Integrity to handle sensitive information in a confidential manner.
  • Ability to accurately enter data into various electronic systems.
  • Professionalism and punctuality.
  • Excellent verbal, written, and interpersonal skills.
  • Ability to complete thorough and accurate psychosocial assessments.
  • Excellent organization skills and ability to multitask, follow-through, and balance multiple priorities independently.
  • Able to work flexibly and reliably within a frequently changing project scope while maintaining overall direction and structured priorities.
  • Strong problem-solving skills.
  • Strong initiative and enthusiasm and willingness to pitch in whenever needed.
  • Eagerness to cultivate new professional contacts and encourage utilization of Lyon-Martin Health Services.
  • Knowledge of resources for underserved people in the Bay Area, preferred.
  • Knowledge of co-occurring disorders, harm reduction and trauma informed treatment, preferred.
  • Knowledge of Clinical documentation (treatment plans, progress notes etc.), preferred.
  • Bilingual English/Spanish speaking skills strongly preferred; additional language ability preferred.
Compensation: TBD
Type: Hourly/ Non-exempt
Benefits: HealthRIGHT 360 offers a competitive benefits package.
City: San Francisco, CA
Hours/wk: 40

Job Location