Care Transitions & Referral Navigator

Community Medical Services; Phoenix (AZ); Hybrid; USD 50,000 - 70,000; Full time

Job summary

Community Medical Services (CMS) is hiring a Transition and Referral Coordinator to oversee client transitions across the full continuum of care with internal and external OTPs, and to wraparound community services with system partners.

This role connects clients to resources, tracks outcomes, coordinates care, and advocates for clients protection and best interests, ensuring patient-centered support across housing, employment, medical, and justice pathways.

Qualifications

• High school diploma or GED required.
• Minimum of two years of experience working with individuals with substance use disorder.
• Three to five years of experience in a clinical or community resource setting with care coordinator and/or case management preferred.
• Ability to travel regularly to CMS sites and partner locations.
• Valid Driver License and Motor Vehicle Clearance (satisfactory driving record for 39 months).
• Basic to intermediate computer knowledge.
• Strong problem solving, conflict resolution, and customer service skills.
• Mission-driven, self-directed with excellent organization and attention to detail.

Responsibilities

• Coordinate client transitions across internal and external OTPs and system partners, including warm handoffs and scheduling.
• Coordinate wraparound service referrals and linkages, and conduct proactive follow-up to track engagement, outcomes, and client experience.
• Coordinate with other departments on discharge and transition plans.
• Maintain reporting, tracking referrals, transitions, and outcomes, escalate partnership barriers as needed.
• Advocate for clients, resolve access barriers, ensure coordinated care across systems.
• Maintain documentation and confidentiality (HIPAA/42 CFR Part 2) including informed consent and related duties.

Skills

Customer service skills

Organizational skills

Communication skills

Problem solving

Conflict resolution

Travel ability

Basic computer knowledge

Education

High school diploma or GED

Tools

EHR system

Microsoft Office

Database management

Job description

Community Medical Services (CMS) is hiring a Transition and Referral Coordinator to oversee client transitions across the full continuum of care with internal and external OTPs, and to wraparound community services with system partners.

This role connects clients to resources, tracks outcomes, coordinates care, and advocates for clients protection and best interests, ensuring patient-centered support across housing, employment, medical, and justice pathways.