Post Care Transitions Specialist (North Central)
About The Position
Trillium Health Resources is hiring a Post Care Transitions Specialist to coordinate care for individuals identified in the Transitions to Community Living Initiative (TCLI) Special Needs Populations. The role focuses on individuals with chronic, unresolved, or complex physical health, behavioral health, and social determinant needs. It includes treatment planning, assessment, monitoring, education, referrals, and linking individuals to services, as well as care planning and discharge and transition planning from Adult Care Homes, inpatient units, and detention centers. The work is grounded in national evidence-based and evidence-informed standards and aims to provide whole-person care. The specialist collaborates with licensed clinicians, registered nurses, and peer support specialists to support successful transitions and post-transition monitoring. The position serves assigned TCLI individuals, assesses support needs for people who have moved into supportive housing, completes assessments as needed, and documents planning and coordination activities in multiple software platforms and State database systems. This position is remote within Trillium’s North Central Region, with travel within the catchment area as required.
Requirements
- Meet Qualified Professional (QP) status through one of the listed pathways: full licensure by the North Carolina governing board regulating human services professions; or North Carolina RN licensure plus four years of full-time MH/DD/SA population experience; or a master's degree in a human service field plus one year of qualifying full-time MH/DD/SA experience or supervised substance abuse counseling experience; or a bachelor's degree in a human service field plus two years of qualifying full-time experience; or a bachelor's degree in a non-human-services field plus four years of qualifying full-time experience. Substance abuse professionals may qualify through the specified supervised alcoholism and drug abuse counseling experience.
- License and/or certification may be accepted as noted.
- Have a valid driver's license.
- Reside in Trillium’s North Central Region: Beaufort, Dare, Edgecombe, Greene, Hyde, Nash, Pamlico, Pitt, Tyrrell, Washington, or Wilson County.
- Be able to travel within the catchment area as required.
- Be legally authorized to work in the United States without requiring employment sponsorship now or in the future.
Nice To Haves
- Experience and knowledge of peer support and experience working with individuals who are certified peer support specialists.
- Bachelor's degree in a human services field and 3 or more years of experience with the MHSU population.
Responsibilities
- Provide care coordination, including treatment planning, assessment, monitoring, education, and referral or linkage to services for assigned TCLI individuals.
- Provide discharge, transition, and post-transition planning and monitoring for individuals transitioning from Adult Care Homes, inpatient units, and detention centers.
- Collaborate with licensed clinicians, registered nurses, and peer support specialists to support successful transitions.
- Coordinate care for individuals with behavioral health, physical health, co-occurring, co-morbid, or multi-morbid conditions.
- Assess members who have transitioned into supportive housing to determine whether additional supports and services are needed for continued independent living.
- Complete assessments as needed.
- Maintain timely and accurate documentation of planning and coordination in multiple software platforms and State database systems.
Benefits
- Health insurance with no premium for employee coverage.
- Flexible Spending Accounts.
- 24 days of paid time off plus 12 paid holidays in the first year.
- North Carolina Local Government Retirement Pension (defined-benefit plan).
- 401(k) with 5% employer match and immediate vesting.
- Quarterly stipend for remote-work supplies.
- Work-from-home options for most positions.
- Flexible work schedules for some roles with management approval.
- Public Service Loan Forgiveness qualifying employer.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
