Continuity of Care (CoC) Liaison - 1832

CENTRAL COUNTIES CENTER FOR MENTAL•Temple, TX

2d•$21•Onsite

About The Position

This position is responsible for promoting continuity, quality, and accessibility of care by coordinating clinical and non-clinical services, supporting successful community reintegration, and ensuring compliance with Texas Administrative Code and HHSC requirements. The CoC Liaison works closely with individuals served, legally authorized representatives (LARs), hospitals, and community providers to prevent service gaps and improve outcomes.

Requirements

Bachelor’s degree from an accredited college or university in Social Work, Psychology, Counseling, Human Services, or a related field
Two (2) years of experience in mental health services, case management, or care coordination
Must have a valid drivers’ license.
Regular attendance and reliability is critical to business operations.

Nice To Haves

Experience working with individuals with serious mental illness (SMI) preferred
Experience coordination care across multiple systems (hospitals, community providers, etc.) preferred
Central Counties Services incorporates principles of trauma-informed care, which includes cultural sensitivity, in all areas of service delivery. All job descriptions include the responsibility to learn about and implement trauma-informed practices within the scope of work for the position.

Responsibilities

Provide continuity of care (CoC) services for individuals admitted to or transitioning from a State Mental Health Facility (SMHF), Private Psychiatric Bed (PPB), or Residential Treatment Center (RTC).
Ensure uninterrupted service delivery from admission through discharge and community reintegration.
Assess and identify medical, psychiatric, psychological, educational, and rehabilitative needs.
Develop and implement individualized discharge and transition plans.
Coordinate treatment, care, and services across multiple systems and providers.
Communicate or ensure CCS staff communicate clinical status and service engagement with facilities prior to or upon admission.
Attend or ensure CCS representation at treatment team meetings.
Maintain ongoing collaboration with state hospitals, psychiatric facilities, and community partners.
Participate in routine meetings with hospital systems to ensure alignment and coordination.
Monitor and track individuals admitted to SMHFs, PPBs, and RTCs.
Ensure quality, consistency, and compliance of CoC activities across admissions and discharges.
Support process improvement initiatives, including exploring technology to enhance coordination and transitions.
Ensure hospital follow-up appointments are scheduled within seven calendar days of discharge to each person discharged from a SMHF, PPB, or RTC.
Ensure psychiatric follow-up appointments are scheduled within required timeframes (within 14 calendar days of discharge or prior to medication depletion, per 26 TAC §306.207).
Identify and coordinate access to non-clinical supports including housing, food, clothing, and educational services.
Assist individuals in securing appropriate living arrangements aligned with their preferences and clinical needs.
Identify and connect individuals to community-based providers and resources.
Ensure compliance with Preadmission Screening and Resident Review (PASRR) requirements when applicable.
Maintain accurate, timely, and complete clinical documentation in accordance with CCS policies and state regulations.
Document all treatment activities and coordination efforts in the clinical record.
Ensure compliance with HHSC rules, CCS standards, and applicable regulations.
Perform additional duties as assigned to support comprehensive, consistent, and person-centered CoC services.