Caregivers / Health Care - Full Time

Peer Care Transition Specialist
Full-time
Title: Peer Care Transition Specialist
Position Type: Full-time, Non-exempt
Reports to: Regional Director of Clinical Behavioral Health and Peer Integration Services
Schedule: Monday - Friday 9am-5pm
ILI) has been increasing access, encouraging self-determination, and advocating for the rights of people with disabilities throughout the Hudson Valley of New York. Following the traditional independent living center (ILC) model, the majority of ILI’s board and staff are individuals with disabilities, bringing valuable peer and life-experience perspectives to the services we provide.
ILI is committed to empowering individuals to live independently and participate fully in their communities.
We encourage applicants to watch our agency video to gain insight into our mission, vision, values, and the impact we make within the community. The video offers a closer look at our culture and the meaningful work our team does every day. Please select the link below for your preferred platform to view the video.
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Join a mission-driven organization dedicated to building a barrier-free society and supporting independent living
Be part of a collaborative workplace that embraces diversity and innovation, where every team member’s voice and lived experience are respected and valued
Be part of an organization that champions inclusive hiring practices and actively welcomes individuals of all abilities, recognizing the value of both visible and non-visible disabilities
Help individuals successfully transition from hospital settings back into the community while making a meaningful impact on recovery outcomes and quality of life
Work alongside hospitals, behavioral health providers, peer specialists, and community organizations to improve continuity of care and reduce barriers to services
The Peer Care Transition Specialist serves as a vital support and advocacy resource for individuals transitioning from hospital and behavioral health settings back into the community. Reporting to the Regional Director of Clinical Behavioral Health and Peer Integration Services, this role works collaboratively with hospital staff, behavioral health providers, Hudson Valley Care Coalition (HVCC) network partners, and community-based organizations to promote continuity of care, reduce barriers to treatment, and strengthen long-term recovery outcomes.
Using lived experience and a recovery-oriented, trauma-informed approach, the Peer Care Transition Specialist helps individuals navigate post-discharge services, engage in behavioral health and medical care, and access community-based supports that promote wellness, stability, and independence. This position also supports Social Care Network (SCN) initiatives through screenings, referrals, and coordination of Health-Related Social Needs (HRSN) services.
Provide peer-based support, mentorship, advocacy, and engagement to individuals during hospitalization and throughout their transition back into the community
Serve as a bridge between hospital-based care, outpatient clinics, peer support services, and community-based providers to promote continuity of care and successful community reintegration
Collaborate with hospital staff, HVCC network providers, care managers, Health Homes, behavioral health providers, and community organizations to support safe discharge planning and coordinated care
Facilitate warm handoffs and ongoing engagement with outpatient clinics, peer support staff, and community programs to strengthen treatment connection and reduce barriers to care
Support individuals in attending post-discharge behavioral health, medical, and primary care appointments through care coordination, reminders, transportation assistance, and follow-up outreach
Assist individuals in identifying goals, strengths, needs, and barriers related to recovery, wellness, and successful community reintegration
Connect individuals and families to community-based resources, including housing supports, food assistance, transportation, benefits, care management, and other social care services
Complete Social Care Network (SCN) screenings, assessments, referrals, and navigation activities in compliance with program and payer requirements
Collaborate with HVCC network providers and community partners to ensure timely linkage to eligible Health-Related Social Needs (HRSN) services
Advocate alongside individuals to ensure their preferences, goals, and needs are reflected in discharge planning and ongoing treatment services
Maintain accurate and timely documentation within electronic health records and required data systems
Participate in multidisciplinary meetings, provider collaborations, and community workgroups focused on improving transition and diversion outcomes
Educate individuals, families, and community partners on available supports, recovery resources, and Independent Living philosophy
Transport individuals to appointments and community-based services, as appropriate
Maintain confidentiality and compliance with all applicable policies, procedures, and regulatory requirements
Personal lived experience as a former or current recipient of mental health, substance use, disability-related, or other human service systems, with comfort using appropriate self-disclosure to support participants
A High School Diploma or GED required
Basic computer proficiency and experience navigating electronic health records, referral systems, and documentation platforms
Demonstrated ability to build trusting relationships and effectively engage individuals transitioning from hospital or structured care settings back into the community
The ability to recognize barriers to care and support individuals in accessing behavioral health, medical, independent living, and community-based services
Experience collaborating with hospitals, behavioral health providers, care managers, Health Homes, and community organizations
Associate’s or Bachelor’s Degree in Human Services, Social Work, Psychology, Rehabilitation, or a related field preferred
Experience working in peer support, behavioral health, healthcare navigation, hospital discharge planning, care coordination, community outreach, or independent living services
Knowledge of Medicaid populations, health equity initiatives, Social Care Networks (SCN), Health-Related Social Needs (HRSN), HCBS, and community-based referral systems
Experience working with individuals with mental health disabilities, co-occurring conditions, or complex healthcare and social care needs
Bilingual English/Spanish skills
Knowledge of American Sign Language (ASL)
Successful engagement and support of individuals transitioning from hospital settings back into the community
Increased attendance and participation in post-discharge behavioral health, medical, and recovery-oriented services
Strong collaboration and communication with hospital teams, HVCC providers, peer specialists, and community partners
Effective completion of SCN screenings, referrals, and coordination of Health-Related Social Needs services
Reduced barriers to care and strengthened continuity of treatment and recovery supports for individuals served
Positive contributions to multidisciplinary teams, transition planning efforts, and improved community reintegration outcomes
Paid holidays from the first day of employment

• Health, Dental and Vision insurance
• Flexible Spending Accounts (FSA)
• Company provided Life, AD&D and Short- and Long-Term disability insurance
• Voluntary insurances including Critical Illness and Hospital Indemnity

We actively support an inclusive hiring process and encourage people with disabilities, visible and non-visible, to apply. If you require reasonable accommodation to support the application or onboarding process, please contact Latoya Merricks at View phone number on click.appcast.io.
We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability status, veteran status, or any other characteristic or status protected by applicable law.