Professional , Behavioral Health Transitional Care Specialist

Professional I, Behavioral Health Transitional Care Specialist

4500 Euclid Ave, Cleveland, OH 44103, USA

Posted Saturday, January 31, 2026 at 5:00 AM

The Behavioral Health Transitional Care Specialist participates in the clinical team by providing short-term case management and care coordination to assist individuals with mental health needs, as they transition out of inpatient care. Provides integrated care by ensuring that whole person health needs are met, including primary and behavioral healthcare, as well as substance abuse services. Works collaboratively with other team members.

Uses high-level engagement skills with individuals, their families, and both internal and external providers to ensure seamless care. Links client to health promotion and wellness activities and helps to make linkages to community services. Maintains a therapeutic relationship with clients on his/her team in meeting the biopsychosocial needs of the client. Facilitates “warm hand-offs” to permanent treatment team.

• A Bachelor’s degree in Social Work, Psychology or a mental health related field required. If in a related field, must have two years care coordination or case management experience.
• A valid driver license in the state of Ohio with access to an insured vehicle for client transportation.
• Prior experience working with severe and persistent mental illness (SPMI) adults preferred.
• A working knowledge of the stages of growth and development and family dynamics.

• Using creativity and a drive for results, act as a liaison for the client to receive community resources.
• The ability to understand and accept a team approach to service delivery, and agency and program philosophy and goals.
• Effective written and verbal communication skills
• The ability to make sound decisions under stressful conditions
• Demonstrated clinical skills, and an ability to organize and prioritize tasks.
• An awareness of and sensitivity to the cultural diversity of the populations served.
• The ability and desire to work closely with other team members.
• The ability to form effective therapeutic relationships to engage clients in the mutual assessment of problems and goal-setting, and to help coordinate care plans from initial contact through end of service.

• Provides short-term community psychiatric support and care coordination which includes health promotion, comprehensive transitional care, individual and family support, and referral, linkage and advocacy relative to community resources.
• Provides high intensity engagement and follow up.
• Conducts level of care assessment.
• Provides services to clients as related to social determinants of health including, but not limited to:
  • Housing/Neighborhood/Environmental needs
  • Social Supports/Community and Peer needs
  • Economic needs
  • Education and Vocational needs
• Ensures that hospital follow up care recommendations are completed including, but not limited to, community psychiatric prescribing and nursing and community mental health case management.
• Works with clients to develop individualized treatment plans and performs treatment plan reviews and updates.
• Communicates vital treatment information from external providers to The Centers treatment team in order to coordinate client care.
• Works on a multidisciplinary service team, in collaboration with Nurses, Physicians, and Pharmacists to achieve positive client health outcomes.
• Actively assists clients in obtaining and maintaining comprehensive healthcare.
• Attends medical appointments with clients as needed. Transports and/or accompanies clients to appointments as needed.
• Provides ongoing communication to client, healthcare teams, and client’s support network to ensure follow-up and coordinated treatment.
• Performs basic administrative tasks related to the job, which includes but not limited to:
  • Completion of clinical records, forms and reports
  • Completion and posting of progress notes within 24 hours of service (Policy P207.00)
  • Completion of daily tracking log
  • Completion of required weekly billable hours
• Performs other related duties as assigned.

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