Transition and Referral Coordinator

Shift: Monday
- Friday 9AM-5PM

Community Medical Services (CMS) is hiring a Transition and Referral Coordinator to oversee client transitions across the full continuum of care with internal and external OTPs, to wraparound community services and system partners. This role connects clients to resources, tracks outcomes, coordinates care, and advocates for clients' best interests, ensuring patient-centered support across housing, employment, medical, justice, and other pathways supporting treatment.

As you join our mission to help those suffering from substance use disorders reclaim their lives, expect to thrive in a comfortable, welcoming, and fun environment where you are valued for the work you do, championed by passionate leaders, and equipped with the tools and ongoing training you need to achieve your goals.

Community Medical Services (CMS) is hiring a Transition and Referral Coordinator to oversee client transitions across the full continuum of care with internal and external OTPs, to wraparound community services and system partners. This role connects clients to resources, tracks outcomes, coordinates care, and advocates for clients' best interests, ensuring patient-centered support across housing, employment, medical, justice, and other pathways supporting treatment.

Along the way, we’ll invest in your well-being through a benefits package that includes:

• Subsidized medical, dental, and vision insurance
• Health savings account
• Short and long-term disability insurance
• Life insurance
• Paid sick, vacation, and holiday time
• 401K retirement plan with match
• Tuition and CME reimbursement up to 100%
• Employee assistance program to support your mental health and wellness
• Ongoing professional development

• Coordinates client transitions across internal and external OTPs and system partners, including warm handoffs, and scheduling.
• Coordinates wraparound service referrals and linkages, and conducts proactive follow-up to track engagement, outcomes, and client experience.
• Coordinates with other departments with discharge and transition plans.
• Maintains related reporting, tracking referrals, transitions, and outcomes, and escalating partnership barriers
• Advocates for clients, resolves access barriers, and ensures coordinated, gap-free care across systems
• Maintains required documentation and confidentiality (HIPAA/42 CFR Part
  2), including informed consent, and completes related administrative tasks

• High school diploma or GED required
• Minimum of two years of experience working with individuals with substance use disorder
• Three to five years of experience in a clinical or community resource setting with care coordinator and/or case management experience preferred
• Ability to travel regularly to assigned CMS sites and partner locations
• Valid Driver License and Motor Vehicle Clearance (satisfactory driving record for 39 months)
• Basic to intermediate computer knowledge
• Problem solving, conflict resolution, and strong customer service skills
• Passion, humility, integrity, positive attitude, mission-driven, and self-directed
• Excellent organizational skills, accuracy, and attention to detail
• Ability to keep accurate notes and records
• Culturally competent and sensitive to client and employee needs
• Ability to communicate clearly and effectively between all organizational levels and with outside providers
• Ability to match client needs with available community services across multiple sectors
• Knowledge of local, state, and federal regulatory requirements

• Previous experience coordinating referrals or transitions across multiple service sectors
• Experience with wraparound service coordination (housing, employment, medical, justice system navigation)
• Experience with database management and outcome tracking
• Bilingual (English/Spanish) communication skills
• Familiarity with local resource landscape and community partnerships

• The ability to use a phone, computer, printer, and copier is required.
• Frequent use of Microsoft office products, including but not limited to Outlook, Word, Excel, and PowerPoint.
• The ability to use the internet and various web browser software is required.
• Proficiency with Electronic Health Record (EHR) system for documentation and care coordination.
• Ability to develop and maintain tracking databases and dashboards (Excel or dedicated database).

• Requires sitting and standing associated…