Continuity of Care Specialist

Job Description

Job Description

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 :

✅ Preferred :

Core Competencies

Working Conditions