Transitions In Care Coord

ing Details

ed: August 7, 2025

Full-Time

Locations

Showing 1 location

Springfield, MA 01103, USA

Job Details

Description

The Transitions in Care (TIC) Coordinator is a grant-funded role that provides critical healthcare coordination for justice-involved individuals transitioning from correctional facilities back into the community. This position splits time between Caring Health Center and Hampden County Correctional Centers, working directly with incarcerated individuals to develop personalized reentry plans, coordinate healthcare services, and ensure seamless transitions back into the community. The TIC Coordinator collaborates with Community Health Workers, Recovery Coaches, correctional staff, and various community partners to address medical, behavioral health, and social needs while supporting program evaluation and quality improvement initiatives.

• Bachelor�s degree (or equivalent experience) in Public Health, Education, Management, or related field.
  
• Oral and written fluency in English (fluency in another language a plus, such as Spanish, Arabic, Russian, Vietnamese, or Nepali).
  
• Experience in administration and management grants or grant-funded programs, including reporting, budget management, and workplan development.
  
• Experience or prior involvement in the development, improvement, or evaluation of health programs/services in community settings.
  
• Strong theoretical understanding of principles of health equity, social determinants of health, community development, and social justice.
  
• Ability to demonstrate cultural humility with staff, teams, patients, stakeholders, and partners representing diverse cultures, ethnicities, sexual orientations, gender identities, socioeconomic statuses, educational backgrounds, worldviews, literacy levels, and languages.
  
• Experience in curriculum/protocol development and group facilitation (e.g., workshops, courses, or focus groups).
  
• Excellent written and oral communication skills.
  
• Strong professional communication and correspondence skills.
  
• Complete proficiency in Microsoft Office (Word, Excel, and PowerPoint) and Google Workspace (Email, Calendar, Drive, Docs, Sheets, and Slides) applications.
  

• Provide one-on-one education and care coordination to Transitions in Care (TIC) clients with the goal to enhance overall health outcomes and support successful transition into the community.
  
• Support the Justice Involved (JI) Program CHW to conduct one-on-one sessions for TIC clients with the goal to leverage their expertise to build trust and gather comprehensive information.
  
• Support project planning and management to ensure all components are aligned and implemented effectively, on time, in scope, and on budget.
  
• Provide strategic direction, monitor progress, and make necessary adjustments to optimize program outcomes, and to ensure that reentry plans are evidence-based and follow best practices.
  
• Coordinate input and guidance from content experts as needed to develop program resources and educational and workflow-related programming materials.
  
• Oversee monthly coordination meetings between the JI Program CHW, Recovery Coach, and local correctional staff to review upcoming releases and discuss the specific needs of individuals scheduled for re-entry.
  
• Coordinate with local correctional stakeholders to ensure justice-involved individuals have obtained necessary resources prior to re-entry, including insurance enrollment in CHC's ACO C3, and to identify and address insurance transfer challenges.
  
• Facilitate with local correctional providers, including the correctional facilities� in-house services to ensure comprehensive, seamless support during the transition to the community for justice-involved individuals.
  
• Establish and facilitate specialized care team and advisory panel of experts, including project partners (Sheriff�s Department, MassLeague of Community Health Centers, C3, Hampden County Continuum of Care (CoC) , and Men of Color Health Awareness (MOCHA) to provide comprehensive and tailored healthcare services for justice-involved populations.
  
• Develop team-based personalized reentry plans with incarcerated individuals, focusing on their individualized health and social needs.
  
• Support the JI Program CHW to coordinate integrated primary care enrollment, continuation of MAT and behavioral health services, and social risk assessment during the intake process for justice-involved individuals.
  
• Oversee implementation of chronic condition management programs, including complex care management, medication therapy management (MTM), and continuous care plans, by a multidisciplinary team of discharge planners, counselors, mental health staff, medical team, and external providers.
  
• Conduct process evaluation comparing planned/actual implementation timelines, identifying barriers and facilitators to delivering integrated medical, behavioral health, and social care to justice-involved patients.
  
• Facilitate co-creation of evaluation inputs with the interdisciplinary team, including JI Program CHW and Peer Recovery Coach, led by research and population health leadership, to support future research on services for justice-involved community members.
  
• Add TIC project to the Annual CHC Quality Improvement (QI) work plan using Plan-Do-Study-Act (PDSA) cycles for implementation, reach, and sustainability, and include measures such as cancer screenings, immunizations, and depression screening/remission rates to ensure high standards of care.
  
• Exercise a high level of organization, attention to detail, and ability to work effectively with diverse stakeholders to ensure timely tracking, completion, and submission of all grant deliverables.
  
• Travel to multiple work locations, including Caring Health Center and the Hampden County Correctional Centers. Reliable transportation is required.
  

• Position requires prolonged periods of sitting at a desk and typing on a computer; ability to stand for prolonged periods of time; ability to perform moderate activities such as climbing stairs, bending, stooping, reaching, and lifting up to 20 pounds at times; and potential exposure to adverse outdoor environmental conditions.
  

Qualifications

Education

Bachelors or better.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.