Care Transition Coordinator

Care Transition Coordinator (Inglewood Adult Services)

This is a hybrid position. Candidates must be local to Southern California with the ability to travel to between sites as needed.

The salary for the position is between $28.90-$33.23 hourly.

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About Didi Hirsch

Didi Hirsch Mental Health Services has been a national leader in whole-person mental health, crisis care, and substance use services since 1942 and is home to the nation's first Suicide Prevention Center. We are a nonprofit organization providing care to about 290,000 people annually across our programs. Didi Hirsch has deep roots in community-based mental health and a commitment to providing culturally responsive services that are just and equitable. More than 1,000 dedicated employees and volunteers make Didi Hirsch's work possible.

Summary

As a Care Transition Coordinator, you will provide outreach, case management, crisis intervention, and connections to therapeutic and community resources for individuals with behavioral health needs transitioning from hospital care to community-based services. You will support client engagement throughout the transition process, helping clients access services and achieve positive outcomes within an integrated healthcare setting. You will coordinate care, advocate for client needs, and work collaboratively with providers and community partners to ensure continuity of care. In addition, you will create a safe, supportive environment that fosters hope, dignity, recovery, and long-term wellness for clients.

Primary Duties

• Acts as the primary, immediate point of contact for hospital patients transitioning to community behavioral health services and community support services.
• Conducts personalized outreach and comprehensive screenings prior to hospital discharge to evaluate behavioral health acuity, immediate safety, and service needs.
• Partners closely with hospital discharge planners and inpatient medical social workers to facilitate a clinically sound "warm handoff" into the community.
• Develops and implements short-term, transitional care plans to bridge the gap between hospital discharge and long-term community placement.
• Assists clients in navigating systems of care to reduce barriers to service access.
• Provides supportive interventions and psycho-education to promote engagement in services and assist clients in coping with mental illness and/or substance use.
• Actively addresses social determinants of health by providing hands-on assistance with immediate needs, including coordinating transportation, navigating health insurance/benefits, and coordinate linkage to food or housing resources.
• Empowers clients through self-management education, helping them understand their care plans, medication schedules, and outpatient resources.
• Interfaces with hospital teams, community providers, and, when appropriate, family members or other supports to coordinate care.
• Executes rapid-response community re-engagement strategies if a client misses an appointment or shows signs of disengagement from their treatment plan.
• Actively tracks and monitors outpatient service utilization for the first six weeks post-discharge to ensure continuity of care.
• Provides intensive and collaborative, field-based outreach, meeting clients in their homes, temporary shelters, or community spaces to foster trust and rapport.
• Develops and maintains rapport and cooperative relationships with community agencies for the benefit of the clients.
• Provides crisis intervention and facilitates conflict resolution among the clients as needed; assists clients in problem-solving life situations.
• Monitors and maintains documentation of client services; ensures compliance with Agency, county, state and federal policies and procedures, standards and guidelines.
• Maintains knowledge of community resources and develops expertise in care transition best practices through ongoing training and professional development.
• Maintains rigorous, timely documentation of all screenings, community field visits, and linkage outcomes in accordance with agency and healthcare partner standards.
• Attends and participates in Agency and program/team meetings, individual/group supervision, and related community Agency meetings as required/requested.

Position Requirements

• Minimum of two years of related experience or a bachelor's degree is required.
• Previous experience working in a social service/mental health environment, preferably with mental health and/or substance use clients within a hospital, care transition, or community-based clinical care setting. Experience in a medical setting is preferred.
• Current knowledge of all job specific skills including crisis intervention and multicultural and socio-economic issues, and documentation standards.
• Bilingual in Spanish preferred but not required.
• Knowledge of Agency policies and procedures, HIPAA, policies and documentation guidelines, and county, state and federal regulations relating to service programs for individuals and families with a history of mental illness and/or substance use.
• Knowledgeable about and actively supports integrated mental health, physical health and substance use treatment for improving care for the whole person.
• Basic advocacy skills to include a holistic approach to integrated health care and case management.
• Skills to present ideas, information, and viewpoints clearly, both verbally and in writing.
• Able to efficiently use the personal computer to include Microsoft Office Suite and Electronic Health Record.
• Ability to travel throughout the community and between agency sites in a timely manner to provide services across a variety of settings, including outpatient and field-based locations (e.g., homes, schools, and other community environments), as needed to meet business and client needs.
• Ability to utilize data, outcomes, experience and judgment to make effective business and therapeutic decisions.
• Demonstrate commitment to team objectives and Didi Hirsch mission.
• Adapt to changing needs by acquiring new skills and knowledge.
• Current California driver's license, car insurance, and a driving record acceptable to the Agency's insurance carrier is required.

Our Vision

A future where everyone has equitable access to care and is empowered to achieve optimal mental health and well-being.

Our Mission

Didi Hirsch provides compassionate mental health, substance use, and suicide prevention services to individuals and families, especially in communities where discrimination and injustice limit access.

Core Values

Excellence: We are constantly innovating, learning from the communities we serve, and applying the latest research to advance best practices. We uphold the highest ethical standards to ensure we are providing compassionate and excellent care.

Diversity & Inclusion: We value diversity of background, experience, and ideas. We celebrate differences and prioritize creating a sense of belonging.

Equity: We are dedicated to promoting health equity in our communities, and we work to dismantle disparities and discrimination within both systems of care and society.

Well Being: We are devoted to the well-being of our staff, volunteers, and communities, and believe healthy teams lead to healthy clients.

Advocacy: We advocate across all levels of government and use our voice to reduce barriers to care with the goal of access to high quality, integrated healthcare for all.

Community Engagement: We build partnerships in the community and across sectors to create a more inclusive and responsive mental health ecosystem and enhance greater accessibility to care and support.

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