Discharge Coordinator

Under the supervision of the Program Director, the Discharge Coordinator supports clients in preparing for and successfully transitioning to the next level of care. This position provides discharge planning, care coordination, resource navigation, and transition support to help clients maintain engagement in treatment and recovery services. The role works collaboratively with the treatment team to address barriers, facilitate continuity of care, and support positive client outcomes.

• High School Diploma or GED required.
• For individuals in recovery from substance use disorder, must have maintained continuous recovery for the previous two years at the time of hire.
• Minimum three (3) years of behavioral health experience required.

• Must maintain a valid Oregon Driver License or ability to obtain one upon hire.
• Must be insurable under Best Care's auto liability policy.
• Must have reliable transportation with adequate insurance coverage.
• Must have a Certification as an OHP Insurance Assister or the ability to obtain one upon hire.

• Associate's Degree in a behavioral health field.
• Experience coordinating discharges, referrals, transitions of care, or community-based services.
• Experience working with individuals experiencing substance use disorders, withdrawal management, residential treatment, or other behavioral health services.
• Bilingual English/Spanish preferred.

• Evaluate client discharge planning needs.
• Develop individualized discharge and continuing care plans.
• Coordinate referrals and transitions to appropriate treatment and support services.
• Schedule and coordinate follow-up appointments prior to discharge.
• Coordinate transportation and travel arrangements supporting transitions of care.
• Coordinate warm handoffs with receiving providers.
• Communicate transition and discharge information to receiving providers.
• Participate in interdisciplinary treatment planning and case review meetings.
• Track referrals, appointments, discharge arrangements, and transition outcomes.

• Assist clients in overcoming barriers to successful discharge and treatment engagement.
• Assist clients in accessing benefits, entitlements, housing resources, employment resources, identification documents, and community resources.
• Support development of recovery, relapse prevention, and safety plans.
• Provide education regarding treatment options, recovery resources, community services, and available support programs.
• Respond to changing client needs and discharge barriers.

• Obtain and maintain required consents, releases, and authorizations.
• Maintain accurate and timely documentation in the electronic medical record and other required systems.
• Ensure information sharing complies with HIPAA, 42 CFR, client consent requirements, and agency policy.

• Develop and maintain collaborative working relationships with providers and community partners.
• Advocate for timely and appropriate transitions of care.
• Assist in identifying alternative resources when preferred options are unavailable.

• Performs special projects and other related duties as assigned.