Lead Navigator

POSITION SUMMARY

The Lead Navigator is the operational lead for the Social Resource Navigator Pilot Program. This role delivers direct navigation services, oversees Volunteer Navigators, maintains the shared resource directory, and serves as a central connector across Sonoma Valley’s senior-serving agencies. The Lead Navigator ensures older adults receive clear, culturally responsive guidance and warm handoffs to the services they need to age with dignity, safety, and independence.

ESSENTIAL DUTIES

DIRECT NAVIGATION SERVICES

• Provide person-centered information, assistance, and options counseling via walk-ins, phone, email, and referrals.
• Conduct structured intake and screening across core domains, including housing and home safety, daily living, transportation, food, health and behavioral health, social connection, caregiving, financial strain, and safety.
• Complete deeper assessments for individuals with higher risk factors such as recent hospitalization, cognitive concerns, unstable housing, or social isolation.
• Co-create written “next steps” plans outlining options, referrals, and responsibilities.
• Make warm handoffs to public, nonprofit, and for-profit providers with client consent.
• Provide short-term follow-up to ensure services are initiated and barriers addressed.
• Recruit, train, and coordinate Volunteer Navigators, including regular meetings and adherence to policies and procedures.

COORDINATION WITH THE AGING & DISABILITY RESOURCE HUB (ADRH)

• Deliver services aligned with ADRH standards, including No Wrong Door access and confidentiality requirements.
• Use shared or compatible intake, referral, and documentation tools. Partner with ADRH staff to ensure clients are connected to appropriate county programs.
• Refer cases requiring higher-level intervention such as APS, IHSS, Medi-Cal LTSS, or complex behavioral health.
• Receive and respond to ADRH referrals for Sonoma Valley residents needing local or in-person support.
• Participate in coordination meetings, trainings, and shared learning with county and partner agencies.

MASTER PLAN FOR AGING & SONOMA COUNTY ALIGNMENT

• Integrate the Five Bold Goals of the California Master Plan for Aging; Housing for All Ages & Stages, Health Reimagined, Inclusion & Equity, Caregiving That Works, and Affording Aging, into daily practice.
• Track and communicate how navigation activities advance county and state Master Plan priorities through data and stories.
• Stay current on local Master Plan initiatives, pilots, and resources to maximize alignment and referral opportunities.

RESOURCE DIRECTORY & PROVIDER RELATIONSHIPS

• Support the quarterly Sonoma Valley Agency Consortium. Build and maintain an up-to-date directory of public programs, nonprofit resources, and vetted for-profit providers.
• Capture and update key details such as eligibility, languages, accessibility, costs, service areas, and referral processes.
• Develop strong working relationships with community partners across sectors.
• Help draft and honor simple MOUs or participation agreements regarding referrals, responsiveness, and client experience.

DATA, QUALITY IMPROVEMENT & REPORTING

• Use a case-management or CRM system to document client contacts, needs, referrals, and outcomes.
• Track and report core metrics including clients served, referral sources, top needs, time to connection, and satisfaction.
• Identify service gaps and share findings with Vintage House leadership and county partners.
• Lead basic quality improvement efforts by refining tools, workflows, and referral processes.

PROGRAM DEVELOPMENT & COMMUNITY OUTREACH

• Help refine and document navigation workflows, tools, and standard operating procedures.
• Support development of additional staffing models such as volunteers, interns, or peer navigators.
• Conduct community outreach and presentations to increase awareness of navigation services.
• Represent Vintage House in coalitions, Master Plan workgroups, and coordination meetings related to aging, disability, housing, health, and caregiving.

REQUIRED QUALIFICATIONS

• Bachelor’s degree in social work, gerontology, public health, human services, or related field; or equivalent experience.
• At least 3 years of direct experience with older adults, adults with disabilities, or caregivers in social services, health care, or community settings.
• Strong knowledge of local aging‑related resources (housing, transportation, food, health/behavioral health, social connection, caregiving, benefits, legal supports).
• Experience with care coordination or case management, including documentation and follow‑up.
• Excellent interviewing, active listening, and person‑centered counseling skills; ability to work respectfully across diverse cultures, languages, and lived experiences, including low‑income, rural, LGBTQ , and communities of color.
• Proficiency with email, word processing, spreadsheets, and CRM systems.
• Strong organizational skills with the ability to manage multiple cases and tasks.
• Ability to maintain confidentiality and handle sensitive information appropriately.

PREFERED QAUILIFICATIONS

• Master’s degree in social work, gerontology, counseling, or related field.
• Experience in an ADRC/ADRH, Area Agency on Aging, community health worker program, or similar model.
• Familiarity with the California Master Plan for Aging.
• Bilingual English/Spanish or another language common in Sonoma County.
• Experience with electronic records or formal referral platforms.

COMPETENCIES & ATTRIBUTES

Commitment to dignity, independence, and self-determination for older adults and adults with disabilities. Equity-oriented mindset and cultural humility. Comfort supporting individuals and families in crisis or navigating complex situations. Strong relationship-building and collaboration skills across public, nonprofit, and for-profit sectors. Initiative, flexibility, and problem-solving in a developing program environment.

WORK CONDITIONS

Primarily onsite at Vintage House with local travel for outreach, meetings, or home visits. Occasional evening or weekend hours for community events or consortium activities. Ability to sit, stand, move throughout the facility, and communicate clearly in person and by phone.

EQUAL OPPORTUNITY STATEMENT

Vintage House is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by law.

Please email a resume and cover letter to David Seyms, david.seyms@vintagehouse.org

Job Type: Full-time

Pay: $70,000.00 - $80,000.00 per year

Benefits:

• Health insurance
• Health savings account
• Paid time off
• Retirement plan
• Vision insurance

People with a criminal record are encouraged to apply

Ability to Commute:

• Sonoma, CA 95476 (Required)

Work Location: In person

Salary : $70,000 - $80,000