Peer Care Transition Specialist

Independent Living Inc•City of Kingston, NY

12d•Onsite

About The Position

The Peer Care Transition Specialist serves as a vital support and advocacy resource for individuals transitioning from hospital and behavioral health settings back into the community. Reporting to the Regional Director of Clinical Behavioral Health and Peer Integration Services, this role works collaboratively with hospital staff, behavioral health providers, Hudson Valley Care Coalition (HVCC) network partners, and community-based organizations to promote continuity of care, reduce barriers to treatment, and strengthen long-term recovery outcomes. Using lived experience and a recovery-oriented, trauma-informed approach, the Peer Care Transition Specialist helps individuals navigate post-discharge services, engage in behavioral health and medical care, and access community-based supports that promote wellness, stability, and independence. This position also supports Social Care Network (SCN) initiatives through screenings, referrals, and coordination of Health-Related Social Needs (HRSN) services.

Requirements

Personal lived experience as a former or current recipient of mental health, substance use, disability-related, or other human service systems, with comfort using appropriate self-disclosure to support participants
A High School Diploma or GED required
Basic computer proficiency and experience navigating electronic health records, referral systems, and documentation platforms
A valid, unrestricted driver’s license and reliable transportation
Demonstrated ability to build trusting relationships and effectively engage individuals transitioning from hospital or structured care settings back into the community
Strong communication, advocacy, interpersonal, and engagement skills with the ability to work effectively with diverse populations
The ability to recognize barriers to care and support individuals in accessing behavioral health, medical, independent living, and community-based services
Experience collaborating with hospitals, behavioral health providers, care managers, Health Homes, and community organizations
Strong organizational and time management skills with the ability to work independently in a fast-paced environment

Nice To Haves

Associate’s or Bachelor’s Degree in Human Services, Social Work, Psychology, Rehabilitation, or a related field preferred
Experience working in peer support, behavioral health, healthcare navigation, hospital discharge planning, care coordination, community outreach, or independent living services
NYCPS (New York Certified Peer Specialist), CRPA (Certified Recovery Peer Advocate), or willingness to obtain certification within one year
Knowledge of Medicaid populations, health equity initiatives, Social Care Networks (SCN), Health-Related Social Needs (HRSN), HCBS, and community-based referral systems
Experience working with individuals with mental health disabilities, co-occurring conditions, or complex healthcare and social care needs
Familiarity with UniteUs, Foothold, or similar electronic documentation and referral systems.
Bilingual English/Spanish skills
Knowledge of American Sign Language (ASL)

Responsibilities

Provide peer-based support, mentorship, advocacy, and engagement to individuals during hospitalization and throughout their transition back into the community
Serve as a bridge between hospital-based care, outpatient clinics, peer support services, and community-based providers to promote continuity of care and successful community reintegration
Collaborate with hospital staff, HVCC network providers, care managers, Health Homes, behavioral health providers, and community organizations to support safe discharge planning and coordinated care
Facilitate warm handoffs and ongoing engagement with outpatient clinics, peer support staff, and community programs to strengthen treatment connection and reduce barriers to care
Support individuals in attending post-discharge behavioral health, medical, and primary care appointments through care coordination, reminders, transportation assistance, and follow-up outreach
Conduct forty-eight-hour, seven-day, and thirty-day post-discharge follow-up contacts, as appropriate
Assist individuals in identifying goals, strengths, needs, and barriers related to recovery, wellness, and successful community reintegration
Connect individuals and families to community-based resources, including housing supports, food assistance, transportation, benefits, care management, and other social care services
Complete Social Care Network (SCN) screenings, assessments, referrals, and navigation activities in compliance with program and payer requirements
Collaborate with HVCC network providers and community partners to ensure timely linkage to eligible Health-Related Social Needs (HRSN) services
Utilize lived experience appropriately to provide encouragement, hope, mentorship, and recovery-focused support
Advocate alongside individuals to ensure their preferences, goals, and needs are reflected in discharge planning and ongoing treatment services
Maintain accurate and timely documentation within electronic health records and required data systems
Participate in multidisciplinary meetings, provider collaborations, and community workgroups focused on improving transition and diversion outcomes
Educate individuals, families, and community partners on available supports, recovery resources, and Independent Living philosophy
Transport individuals to appointments and community-based services, as appropriate
Maintain confidentiality and compliance with all applicable policies, procedures, and regulatory requirements