transition coordinator

1. Review the behavioral health inpatient census daily to identify new admissions, ongoing hospitalizations, and discharged members.
2. Identify individuals who meet the criteria for the Transition of Care program.
3. Conduct timely outreach and structured follow-up calls after hospital discharge to confirm stability, review care instructions, assess safety, and address post-discharge needs, symptoms, risk factors, and barriers to recovery.
4. Review discharge instructions, prescribed medications, scheduled follow-up appointments, and treatment plans with members to promote adherence.
5. Assist members in scheduling follow-up appointments with behavioral health providers, and arrange urgent psychiatric or crisis services when indicated.
6. Evaluate risk for readmission, relapse, medication non-adherence, or deterioration of mental health.
7. Communicate with inpatient teams to track clinical status, discharge readiness, and barriers to transition.
8. Coordinate ambulatory services with mental health providers, partial hospitalization programs, intensive outpatient programs (IOP), and community case management as appropriate.
9. Collaborate with providers and the pharmacy department to resolve issues related to refills, cost, interactions, or access to medication.
10. Assess social determinants of health, including housing insecurity, food instability, and transportation needs.
11. Provide mental health-focused interventions, including education on diagnosis, treatment adherence, early warning signs of relapse or crisis, and strategies for safe and supportive home management.
12. Use a collaborative approach with internal departments and stakeholders (Quality, Financial, Pharmacy, Utilization, Access Center) to coordinate services and track utilization and progress toward recovery.
13. Assist members with a safe transition of care from one setting to another.
14. Assist members when physical needs are identified and facilitating access to the appropriate services through the medical plan to ensure proper and timely management.
15. Advise individuals, families, and significant others on available options to support their recovery process.
16. Participate in case discussions with mental health providers and other community or governmental agency professionals.
17. When appropriate and if the member is identified as benefiting from case management services, submit a referral to the program to address their needs.
18. Comply with and promote established confidentiality regulations.
19. Document clinical information promptly in the appropriate platforms.
20. Advise individuals, families, and significant others on available options to support their recovery process.
21. Comply with and promote the established confidentiality regulations.

1. Document the clinical information on time on the appropriate platforms.

1. In compliance with the policies, procedures, and code of ethics maintains a therapeutic relationship with the family or support system.

1. Serve as a liaison between member's family, mental health providers and physical health providers.

1. Analyses and discuss cases with the psychiatric hospitals' clinical personnel when necessary.

1. Practices cultural competency, conscientiously, and with respect for diversity.

1. Promotes and incorporates the use of evidence-based practices and empowerment strategies with an emphasis on prevention of exacerbations and complications.

1. Represents the program or the corporation in interdepartmental meetings, with government agencies, commercial accounts, IPAs, for profit and nonprofit organizations, among others.

1. Keeps the specialization license and professional association membership (colegiación ) effective.

1. Complies with the continuing education hours that correspond to the specialization.

1. Participates in the mandatory training courses, such as: Ethics, Annual Compliance Plan, URAC, NCQA and CMS guidelines and regulations.

1. Inform the director or human resources of any sanction or revocation of your license that affects the practice of your profession.

1. Available to travel throughout Puerto Rico.

1. Other tasks assigned by the director.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.

Notice

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries.  We take pride in creating highly efficient and best-in-class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or