Transitions of Care Specialist

Center for Life Management (CLM) provides the area's most comprehensive array of outpatient mental health services for adults and elders. Our multi-disciplined treatment team works with individuals ages 18 who experience severe and persistent mental illness and/or co-occurring substance use disorders. The Transitions of Care Specialist creates successful linkages for appropriate and effective services at Center for Life Management to clients who have completed a recent intake. This position identifies client transition needs and engages the individual in various interventions while they await permanent staff assignment. Interim services to be provided may include care planning, resource identification, benefit coordination, service monitoring, and community-based supportive counseling to assist clients with improving symptoms and behaviors that otherwise interfere with daily functioning and wellness goals. In addition, the Transitions of Care Specialist provides coordination of care for clients in the Healthy Together primary care program. This is a full time, 40 hour per week position.

Major Functional Areas and Description of Duties

• Provide extensive outreach, case management and community-based services to clients on the disposition (dispo) waitlist who are awaiting permanent treatment assignment;
• Provide individual assessment to create care plans that specify presenting problems, objectives, interventions, and desired outcomes;
• Assist clients with applying for and maintaining adequate medical coverage to support consistent access to whole health care and treatment;
• Provide outreach, advocacy, coordination, resource identification, linkage and monitoring of internal and external supports and services;
• Provide Individual Therapeutic Behavioral Services (TBSI) to develop, apply, and reinforce coping strategies to reduce and/or ameliorate symptoms and behaviors that interfere with functioning and goal achievement;
• Provide Crisis Intervention (CI) when clients experience acute exacerbation of symptoms to ensure their safety within the home and/or community;
• Develop priority assignment of cases for dispo and articulate client needs effectively for proper case placement;
• Work collaboratively with other treatment team members, natural supports, and external providers to ensure a wrap-around approach is provided for continuity of client care;
• Serve on appropriate committees, both internal and external, as determined by supervisor;
• Function professionally and in a manner that protects the integrity, confidentiality and rights of all patients;
• As directed by prescribing staff, coordinate personalized care for all Healthy Together

patients to include but not limited to primary care physicians, specialists, guardians, and

internal and external ancillary supports;

• Attend weekly Healthy Together huddle, take detailed notes, and complete documentation in EHR- sending to treatment teams involved as appropriate;
• Ensure Healthy Together staff involved in a client’s care are up to date with case information for continuity of care;
• Educate and guide patients in the Healthy Together program via linkage and referral to community programs and resources, ensuring they get their needs met effectively;
• Execute all required services and timely documentation on each service delivered in accordance with agency policies and federal/state standards;
• Maintain professional memberships, licenses, accreditation, certifications, etc.;
• Represent CLM in a professional and appropriate manner in all settings;
• Perform all other duties as assigned by supervisor.

Qualifications and Skills

• Bachelor’s degree in a behavioral health discipline preferred;
• Demonstrated experience working with adults with mental health challenges including experience navigating the behavioral health system;
• Familiarity with service delivery and community-based treatment Center for Life Management provides;
• Ability to foster self-sufficiency of individuals using problem-solving and practical skills;
• Ability to exercise sound clinical judgment in routine, urgent, and emergent situations;
• Proficient computer skills, specifically with all Microsoft office applications;
• Excellent communication skills with ability to document effectively and efficiently in course of clinical work;
• Ability to navigate an electronic health record;
• Ability and desire to work as part of a clinical team while also able to be self-directed and motivated with minimal supervision;
• Ability to acquire and effectively practice new clinical skills as needed according to evolving agency needs/services;
• Effective communication skills, organizational skills, and ability to multi-task.