Peer Care Transition Specialist

About the Role

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.

What You’ll Do 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

Requirements

The Ideal Candidate Will Have 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

It Would Be a Plus If You Also Have 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)

Success in This Role Will Be Demonstrated Through Successful engagement and support of individuals transitioning from hospital settings back into the community Increased attendance and participation in post-discharge behavioral health, medical, and recovery-oriented services Strong collaboration and communication with hospital teams, HVCC providers, peer specialists, and community partners Effective completion of SCN screenings, referrals, and coordination of Health-Related Social Needs services Reduced barriers to care and strengthened continuity of treatment and recovery supports for individuals served Accurate, timely, and compliant documentation, reporting, and follow-up activities. The ability to empower individuals through peer support, advocacy, mentorship, and recovery-focused engagement Positive contributions to multidisciplinary teams, transition planning efforts, and improved community reintegration outcomes

Benefits

available to you include Paid holidays from the first day of employment Paid lunch break Paid time off 401(k) with company match Health, Dental and Vision insurance Flexible Spending Accounts (FSA) Company provided Life, AD&D and Short- and Long-Term disability insurance Voluntary insurances including Critical Illness and Hospital Indemnity

We actively support an inclusive hiring process and encourage people with disabilities, visible and non-visible, to apply. If you require reasonable accommodation to support the application or onboarding process, please contact Latoya Merricks at (845) 674-7752.

ILI is proud to be an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability status, veteran status, or any other characteristic or status protected by applicable law.

To apply, visit us at https://www.myindependentliving.org/careers/

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