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Eliot Community Human Services BH CP Care Transitions Coordinator "Hybrid work schedule" Spanish Speaking Preferred in Boston, Massachusetts


$3000 Sign On Bonus!

Eliot is seeking a Care Transitions Coordinator with a bachelor’s degree or master’s degree and with three years’ direct experience in Care Management or Case Management or must be a Certified Peer Specialist or Certified Recovery Coach. May substitute one year of experience with a college degree in the human services field if a Peer Specialist or Recovery Coach. The ideal candidate will have a strong commitment to mental health recovery, substance abuse disorders, care coordination, and wellness.

Eliot’s Behavioral Health Division provides an integrated and comprehensive network of services to adults with psychiatric disabilities that are evidence based, provide rehabilitation and hope to those in services. Eliot's Behavioral Health Community Partner (BHCP) program is an innovative Care Management approach for MassHealth members with complex medical, behavioral health and social needs who are part of the new Accountable Care Organization (ACO) redesign within Massachusetts.

Responsibilitie s:

  • Promote hope and empowerment through meetings with and support of individuals.

  • Empower individuals to exercise autonomy in all aspects of life. Assist enrollees with identifying choices and developing skills in self advocacy.

  • As a member of Care Transitions Team, collaborate with Nurse Care Managers to triage hospital admissions data and formulate assertive follow-up strategies to make contact with hospital treatment teams and enrollees during inpatient admissions

  • Facilitate collaborative discharge planning process for hospitalized enrollees during admissions through phone and face-to-face communication with enrollees and inpatient treatment teams. Ensure that required post-discharge activities and follow-up appointments with providers are scheduled prior to discharge

  • Coordinate and ensure timely face to face contact with enrollees in the community following inpatient discharge within timeframes dictated by MassHealth contract.

  • Communicate discharge disposition updates to assigned Care Manager throughout enrollee inpatient admissions and consult with and/or directly involve assigned Care Manager in the process, as needed.

  • Ensure that discharge plans incorporate follow-up activities and service referrals that match enrollee needs and preferences to reduce the likelihood of readmission.

  • Model and professional communication and conduct toward inpatient facility and ACO/MCO collaterals to foster and maintain strong working partnerships.

  • Follow each hospitalized enrollee through discharge process until all required follow-up activities are completed.

  • May be assigned as primary Care Coordinator for a number of enrollees to provide ongoing community-based care coordination, based on program needs. If primary Care Coordinator, would be responsible for tasks including but not limited to: outreach and engagement, enrollment, completing comprehensive assessments, developing care plans, and developing and implementing interventions that promote health and wellness, match enrollee needs and preferences and incorporate appropriate ACO, Care Team and other community collaterals.

Schedule: Monday-Friday 9am-5pm

Salary: $50,000 annually

Eliot is committed to identifying and dismantling barriers that prevent people with marginalized racial identities from actualizing their full employment potential, assuming leadership roles, or from fully engaging at all levels in the workplace.

Bonus Breakdown:

  • Completion of one month's employment: $1,500

  • Completion of 6 months' employment (probationary period): $1,500




  • Communication Skills: Intermediate

  • Computer Software Skills: Intermediate

  • Administrative Tasks: Intermediate



  • Bachelors or better in Psychology

Licenses & Certifications


  • MA Driver's License



  • 3 years: Experience Care Management or Case Management