Integrated Care Transition & Referral Specialist

Socket.dev; Phoenix (AZ); On-site; USD 42,000 - 54,000; Full time

Benefits offered by this job

Subsidized medical, dental, and vision

Health savings account

Short and long-term disability

Life insurance

Paid sick and vacation time

401K retirement plan with match

Tuition and CME reimbursement up to %

Employee assistance program

Ongoing professional development

Job summary

Community Medical Services (CMS) in Phoenix, AZ is hiring a Transition and Referral Coordinator to oversee client transitions across the continuum of care with internal and external OTPs, wraparound services, and system partners. You will link resources, track outcomes, and advocate for clients' best interests to ensure patient-centered support across housing, employment, medical, and justice pathways.

Join a mission-driven team emphasizing training, growth, and a supportive environment with

Qualifications

• High school diploma or GED required.
• Minimum of two years experience working with individuals with substance use disorder.
• Three to five years of clinical or community resource setting with care coordinator and/or case management experience 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.
• Problem solving, conflict resolution, and strong customer service skills.
• Passion, humility, integrity, positive attitude, mission-driven, and self-directed.
• Excellent organizational skills, accuracy, and attention to detail.
• Ability to keep accurate notes and records.
• Culturally competent and sensitive to client and employee needs.
• Ability to communicate clearly and effectively between all organizational levels and with outside providers.
• Ability to match client needs with available community services across multiple sectors.
• Knowledge of local, state, and federal regulatory requirements.

Responsibilities

• Coordinates client transitions across internal and external OTPs and system partners, including warm handoffs, and scheduling.
• Coordinates wraparound service referrals and linkages, and conducts proactive follow-up to track engagement, outcomes, and client experience.
• Coordinates with other departments with discharge and transition plans.
• Maintains related reporting, tracking referrals, transitions, and outcomes, and escalating partnership barriers
• Advocates for clients, resolves access barriers, and ensures coordinated, gap-free care across systems
• Maintains required documentation and confidentiality (HIPAA/42 CFR Part 2), including informed consent, and completes related administrative tasks

Skills

Strong communication skills

Excellent organizational skills

Problem solving

Attention to detail

Cultural competency

Education

High school diploma or GED

Tools

Microsoft Office

EHR system

Database tracking

Job description

Community Medical Services (CMS) in Phoenix, AZ is hiring a Transition and Referral Coordinator to oversee client transitions across the continuum of care with internal and external OTPs, wraparound services, and system partners. You will link resources, track outcomes, and advocate for clients' best interests to ensure patient-centered support across housing, employment, medical, and justice pathways.

Join a mission-driven team emphasizing training, growth, and a supportive environment with