Transition Care Coordinator – Mental Health and Substance Use Treatment

Position Overview

The Transition Care Coordinator plays a critical role in supporting individuals transitioning between levels of care in the mental health and substance use treatment continuum. This position ensures seamless coordination of services, promotes continuity of care, and addresses barriers to recovery. The coordinator acts as a bridge between clients, treatment providers, community resources, and support systems, fostering client-centered recovery plans and maintaining strong collaboration across multidisciplinary teams.

• Care Transition Planning
  • Collaborate with inpatient, outpatient, and community-based providers to facilitate smooth transitions for clients.
  • Develop individualized transition plans tailored to the client’s needs, strengths, and recovery goals.
• Client Support and Advocacy
  • Provide direct support to clients navigating changes in their care, including discharge from hospitals, residential programs, or detox facilities.
  • Serve as a primary point of contact for clients and their families during transitions, advocating for their needs and addressing any concerns.
• Resource Coordination
  • Connect clients to appropriate mental health and substance use treatment services, housing, employment, and other community resources.
  • Assist with referrals, scheduling follow-ups, and ensuring timely access to services.
  Collaboration and Communication
  • Coordinate care across multidisciplinary teams, including therapists, case managers, medical providers, and peer support specialists.
  • Maintain consistent communication with clients, families, and providers to address gaps or challenges in care.
• Monitoring and Follow-Up
  • Monitor client progress during and after transitions, providing follow-up support to address evolving needs.
  • Document all interactions, plans, and outcomes in accordance with agency and regulatory standards.
• Education and Empowerment
  • Educate clients and their families on the recovery process, available resources, and strategies for maintaining wellness and sobriety.
  • Empower clients to take an active role in their recovery by building self‑advocacy and life skills.

• Bachelor’s degree in social work, psychology, counseling, or a related field (Master’s degree preferred).
• 2+ years of experience in mental health, substance use treatment, or care coordination.
• Knowledge of community resources, treatment options, and recovery principles for mental health and substance use disorders.
• Strong organizational, communication, and interpersonal skills.
• Ability to work independently while collaborating effectively within a team.
• Proficiency in electronic medical records and documentation.
• Valid driver’s license and reliable transportation may be required.

• Certification in case management, peer support, or a related field.
• Lived experience with mental health and/or substance use recovery is valued and appreciated.
• Bilingual capabilities are a plus.

• Client-centered and trauma-informed care approach.
• Cultural humility and sensitivity.
• Problem-solving and crisis management skills.
• Commitment to ethical practices and confidentiality.