Care Transitions Care Manager (North-Central)

TRILLIUM HEALTH RESOURCES•Greenville, NC

17h•$56,270 - $68,428•Remote

About The Position

Trillium Health Resources is seeking a Care Transitions Care Manager to join their team. This role is responsible for providing in-reach and transition care management to members in institutional, congregate, or facility-based settings. The Care Transitions Care Manager will educate members and guardians on navigating physical, behavioral, and social service systems, and facilitate access to community resources. The position involves care planning based on evidence-based standards for whole person care, providing guidance to providers on member needs, and completing required documentation in Trillium’s software platform. The role also includes working on an interdisciplinary team to address Olmstead Settlement and Tailored Plan functions, and assessing/monitoring member health and safety, including during states of emergency.

Requirements

Must meet QP status.
Fully licensed by the NC governing board regulating Human Services professions; OR
Fully licensed RN who is licensed to practice in the state of NC by the NC Board of Nursing who also has four (4) years of full-time experience with the MH/DD/SA population served; OR
A graduate of a college or university with a Master’s degree in a human service field and has one year of full-time, pre or post-graduate degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has one year of full-time, pre or postgraduate degree accumulated supervised experience in alcoholism and drug abuse counseling; OR
A graduate of a college or university with a bachelor's degree in a human service field and has two years of full-time, pre or post-bachelor's degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has two years of full-time, pre or post bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling; OR
A graduate of a college or university with a bachelor's degree in a field other than human services and has four years of full-time, pre or post-bachelor's degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has four years of full-time, pre or post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling.
Must have a valid driver’s license.
Must reside within Trillium’s North Central Region, which includes the following counties: Beaufort, Dare, Edgecombe, Greene, Hyde, Nash, Pamlico, Pitt, Tyrrell, Washington, and Wilson.
Must be able to travel within catchment as required.

Nice To Haves

License and/or certification may be accepted as noted above.

Responsibilities

Provide age- and developmentally appropriate education for the member and the member’s family members and/or guardians about the opportunity to receive care in a more integrated community-based setting and available services in such settings.
Provide complex care management, in compliance with NCQA and any other identified regulatory/required accreditation standards, to assigned members who may have identified needs with behavioral health, physical health, co-occurring, co-morbid or multi-morbid conditions.
Provide the member and/or the member’s family members or guardians opportunities to meet with other individuals with SMI/SPMI diagnoses who are living, working, and receiving services in a community setting.
Identify, document, and attempt to address barriers to relocation to a more integrated community setting.
Engage members who are residing in such as State Psychiatric Hospitals, ACH to provide education about permanent supportive housing, supports, services, and other community resources.
Educates members and guardians about how to effectively navigate the physical, behavioral, and social service systems for themselves and about the existence of informal/community resources available to them; and facilitates the member/guardian access to these resources.
Provides care planning with foundations in national evidence based and informed standards for whole person care.
Provides guidance and monitoring to providers regarding social determinant needs, medical needs, and other needs of the member.
Completes required documentation, paperwork, and tasks in Trillium’s software platform in accordance with designated timeframes.
Works on an interdisciplinary team to address the functions of the Olmstead Settlement and Tailored Plan.
Assesses and monitors the member’s health and safety, including when the Trillium Catchment is under a state of emergency or weather advisory.