Care Transitions Care Manager (Southern Region/Lenoir County)

TRILLIUM HEALTH RESOURCES•Lumberton, NC

23h•$56,270 - $68,248•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, as well as informal/community resources, and facilitate access to these resources. The position involves care planning based on national evidence-based standards for whole person care, providing guidance to providers on member needs (social determinants, medical, etc.), and completing required documentation in Trillium’s software platform within designated timeframes. 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 75 miles of Trillium’s Southern Region, specifically Lenoir County.
Must be able to travel within catchment as required.

Nice To Haves

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

Responsibilities

Provide in-reach and transition care management to members residing in institutional, congregate, or facility-based settings.
Educate members and guardians on navigating physical, behavioral, and social service systems and informal/community resources.
Facilitate member/guardian access to community resources.
Provide care planning with foundations in national evidence based and informed standards for whole person care.
Provide guidance and monitoring to providers regarding social determinant needs, medical needs, and other needs of the member.
Complete required documentation, paperwork, and tasks in Trillium’s software platform in accordance with designated timeframes.
Work on an interdisciplinary team to address the functions of the Olmstead Settlement and Tailored Plan.
Assess and monitor the member’s health and safety, including during states of emergency or weather advisories.
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 State Psychiatric Hospitals, ACH to provide education about permanent supportive housing, supports, services, and other community resources.