Complex Transitional Care Nurse (North Central)
About The Position
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Trillium Health Resources has a career opening for a Complex Transitional Care Nurse to join our team! The core responsibility of the Complex Transitional Care Nurse is to develop personalized care planning strategies. This involves a thorough assessment of the patient's unique situation, taking into account their medical history, social circumstances, and individual needs. The care plans are meticulously crafted with foundations in national evidence based and informed standards, ensuring the delivery of whole person care. This evidence-based approach is crucial for achieving optimal patient outcomes and promoting long-term well-being.
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 North Central Region, which includes the following counties: Beaufort, Dare, Edgecombe, Greene, Hyde, Nash, Pamlico, Pitt, Tyrrell, Washington, Wilson.
- 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
- Coordinate care for assigned individuals who may have identified needs with behavioral health, physical health, co-occurring, co-morbid or multi-morbid conditions.
- Collaborate with internal staff across various disciplines/teams to facilitate integrated care.
- Monitor the Care Plan (physical, behavioral health and social determinant concerns), service delivery and health and safety of the member.
- 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
- Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval.
- Work-from-home options available for most positions
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
