Care Transition Coordinator

Job Description

Job Description

Benefits/Perks
Medical, Dental, and Vision Insurance
Life Insurance
Disability Insurance
403(b) Retirement Plan
Paid Time Off (PTO)
Paid Holidays
Flexible Spending Account (FSA)
Employee Assistance Program (EAP)
Eleos Health HIPAA-compliant documentation tool

Company Overview
Mental Health Resource Center is a not-for-profit Florida corporation that provides a wide range of mental and behavioral health services to the community, including 24-hour emergency services, inpatient psychiatric care for children, adolescents, and adults, and outpatient services such as medication management, case management, and counseling.

Job Summary
The Care Coordinator in the Care Transitions program supports high-risk individuals who are not effectively connected to services needed for successful transition from higher levels of care to community-based settings. This role focuses on uninsured or underinsured individuals at risk for frequent use of acute care services, including crisis stabilization, inpatient, and detox services. The Care Coordinator assesses needs, develops and coordinates care plans, and conducts outreach to engage individuals referred from inpatient psychiatric facilities, jails, and other community providers.

Responsibilities

• Serves as the primary coordinator of services, supports, and cross-system collaboration to address the individuals holistic needs.
• Builds trust and rapport through community-based outreach and encourages involvement of natural supports.
• Utilizes LOCUS to determine appropriate level of care.
• Develops person-centered, strength-based care plans that reflect individual preferences and goals.
• Promotes service delivery in inclusive, accessible, and least restrictive environments.
• Integrates services across behavioral health, physical health, housing, social services, education, and employment.
• Uses releases of information (ROIs) and complies with federal and state regulations to coordinate care among providers and supports.
• Facilitates face-to-face introductions to ensure continuity of care and successful transitions.
• Respects and incorporates individuals cultural values, beliefs, and identities into care planning.
• Establishes measurable goals, monitors progress, and adjusts plans as needed.
• Assists with stabilization through ongoing coordination, assessment, and outreach.
• Connects individuals to necessary services and resources, coordinating and monitoring effectiveness and satisfaction.
• Engages individuals referred from hospitals, jails, and other providers and educates them on available services.
• Maintains regular communication, including during psychiatric appointments and as needed to support care coordination.
• Educates community providers on available services and collaborates during crisis points in care.

Documentation Tool (Eleos Health)

• Reduces time spent on documentation, allowing more focus on client interaction and care
• Transforms brief notes or session conversations into complete, clinically appropriate documentation
• Supports accurate, compliant documentation while allowing staff to review and finalize notes
• Provides helpful insights from sessions to support care planning and continuity
• Accessible on desktop or mobile for flexibility across different work settings

Qualifications

• Bachelors degree in Social Work or a related Human Services field from an accredited university or college (a related Human Services field is defined as one in which 30 hours of course work includes the study of human behavior and/or development) required.
• Minimum of one year of experience in human services or a mental health-related field required.
• Must demonstrate proficiency in MHRC EHR System within three months of employment.
• Proficiency in Microsoft Office and email are required.
• Must meet Frequent Drivers requirements, including a valid Florida drivers license, and insurance coverage equal to or exceeding 50,000/100,000/50,000 split limits.
• Excellent customer service skills are essential and this individual must be able to interact appropriately with internal and external customers, including individuals served, families, caregivers, community service providers, supervisory staff and other department professionals.

Position Details
This is a Full Time Days position. Renaissance Behavioral Health Systems and Mental Health Resource Center are Equal Opportunity Employers.
Background screening and clearance through the Florida Care Provider Background Screening Clearinghouse is required for all positions: