Care Coordinator – Hospital Transitions

About the role

The Care Coordinator – Hospital Transition plays a crucial role in ensuring seamless transitions from hospital care to community-based services. This position focuses on coordinating pre-discharge planning, conducting post-discharge follow-ups, and building strong relationships with hospital staff.

Responsibilities

• Serve as the primary point of contact between hospitals and Heritage
• Coordinate pre-discharge planning to ensure needed supports are arranged
• Conduct post-discharge follow-up with clients to support engagement and remove barriers
• Complete IATPs prior to discharge to ensure immediate access to care
• Build and maintain professional relationships with hospital teams across Illinois
• Collaborate with internal clinical and case management teams
• Document assessments, coordination activities, and outcomes efficiently and accurately
• Attend multidisciplinary and care planning meetings
• Identify gaps in hospital-to-community transitions and recommend improvements
• Maintain knowledge of hospital procedures, community resources, and regulatory requirements
• Perform additional duties as assigned to support agency mission

Requirements

• High School Diploma or GED + 5 years of supervised mental health or social service experience required
• Bachelor’s degree in social work, psychology, education, or human services preferred
• Minimum 21 years of age
• Valid driver’s license, reliable transportation, and proof of automobile insurance

Qualifications

• Strong understanding of hospital discharge processes and behavioral health systems
• Excellent care coordination, problem-solving, and time-management capabilities
• Effective communication and collaboration skills
• Cultural competence in working with diverse groups and individuals with complex needs
• Ability to lift 10 pounds

Skills

• Quickly build rapport with clients, families, and hospital partners
• Comfort with statewide travel across hospital settings

Benefits

• Generous Time Off: Vacation, sick, personal, and holiday leave
• Wellness Benefits: Every other Friday off (paid wellness day)
• Employee Assistance Program (EAP)
• Fitness reimbursement
• Insurance: Health, dental, and vision
• Flexible spending accounts (healthcare and dependent care)
• Substantial employer contribution toward health insurance premiums
• Retirement: 401(k) and Roth options
• Professional Growth: Tuition assistance and continuing education opportunities
• Loan Forgiveness Eligible through the National Health Service Corps (NHSC)