Complex Transitional Care Nurse

TRILLIUM HEALTH RESOURCES • Greensboro, NC

3d • $66,240 - $88,595 • Remote

About The Position

Trillium Health Resources is seeking a Complex Transitional Care Nurse to provide Complex Care Coordination for individuals with chronic, unresolved, or complex physical, behavioral health, and social determinant needs. This role involves care planning based on national evidence-based standards for whole-person care and completing required documentation in a software platform within specified timelines.

Requirements

• Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse (RN) with a minimum of one (1) year experience as a Registered Nurse.
• Must have a valid driver’s license.
• Must reside within Trillium’s Mid State Region, which includes the following counties: Anson, Guilford, Montgomery, Randolph, and Richmond.
• Must be able to travel within catchment as required.

Nice To Haves

• Experience working with BH/MH/SU/IDD population.
• Knowledge of QM, UM procedures as well as experience in using data analytics for population health management.
• Experience assessing and coordinating care for members in adult care homes, family care homes, home residence or other settings.

Responsibilities

• Complex care coordination to assigned individuals who may have identified needs with mental health, physical health, co-occurring, co-morbid or multi-morbid conditions.
• Collaborate with Internal Staff across discipline/teams (Care Coordinators, Clinicians, OT, COTA, Housing Specialists, Peers, etc.) to facilitate integrated care.
• Monitor the Care Plan (physical, behavioral health and social determinant concerns), service delivery and health and safety of the members.
• Perform clinical functions of discharge/transition planning and diversion including clinical interviewing; obtaining and reviewing clinical records; identifying potential treatment needs; assessing barriers to treatment and recommending solutions; and assessing general health needs and recommending referrals.
• Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.

Benefits

• Health Insurance with no premium for employee coverage
• Flexible Spending Accounts
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
• NC Local Government Retirement Pension (defined-benefit plan)
• 401k with 5% employer match and immediate vesting
• Public Service Loan Forgiveness (PSLF) qualifying employer
• Quarterly stipend for remote work supplies

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level