Continuity of Care Specialist

Department: Clinical Services / Case Management Reports To: VP Case Management/Social Services

FLSA Status: Exempt


Position Summary

The Continuity of Care Specialist is responsible for supporting seamless transitions across the care continuum by coordinating services before, during, and after episodes of care. This role ensures that clients receive appropriate follow-up services, helping to reduce service disruptions, promote engagement, and enhance health and wellness outcomes. The specialist collaborates with multidisciplinary teams, external providers, and families to support individualized continuity plans that address both clinical and social determinants of health.

Essential Duties and Responsibilities

Care Transition Management

• Coordinate and monitor individualized continuity of care plans that support client stability post-discharge or program completion.
• Facilitate communication and handoffs between providers, including hospitals, outpatient clinics, behavioral health teams, and community agencies.
• Ensure timely connection to follow-up care, including medical appointments, behavioral health services, housing support, and other wraparound resources.

Patient and Family Support

• Serve as a primary point of contact for patients during transition periods to ensure ongoing engagement.
• Provide education and support to patients and their families regarding discharge plans, community resources, and care expectations.
• Address barriers to care such as transportation, documentation, and access to benefits.

Documentation and Compliance

• Maintain accurate and timely documentation of service coordination activities in the electronic health record (EHR) system.
• Monitor and document patient follow-through on recommended services and referrals.
• Ensure compliance with organizational policies, HIPAA regulations, and applicable funding or licensing requirements.

Interdisciplinary Collaboration

• Participate in multidisciplinary team meetings and case reviews to share updates and inform treatment planning.
• Establish and maintain working relationships with referring providers, payers, and support organizations.
• Contribute to systems-level improvement efforts aimed at strengthening continuity of care pathways.

Minimum Qualifications

• Required:

• Bachelor's degree in Social Work, Nursing, or a related field.
• Minimum of 2 years of experience in care coordination, case management, discharge planning, or similar roles.
• Knowledge of health systems, behavioral health services, and social service navigation.
• Excellent interpersonal, organizational, and communication skills.

• Preferred:

• Master's degree (MSW, RN, etc.) or active professional license (e.g., LCSW, RN).
• Experience working with high-risk or underserved populations.
• Familiarity with trauma-informed and culturally responsive care.
• Bilingual or multilingual skills.

Core Competencies

• Client-centered and trauma-informed approach
• Cultural humility and health equity
• Effective communication and advocacy
• Systems thinking and collaborative problem-solving
• Ethical practice and professional boundaries

Working Conditions

• Centralized office with facility onsite requirements to ensure patient/family/physician interaction.
• May require flexible scheduling to meet patient needs.
• Use of electronic systems and secure platforms is essential.