Transition Care Coordinator (Mid State)

TRILLIUM HEALTH RESOURCES•Greensboro, NC

3d•Remote

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 Transition Care Coordinator to join our team! The Transition Care Coordinator (TCC) is responsible for providing care coordination (treatment planning, assessment, monitoring, educating, and referral/linking) to individuals identified in the Transitions to Community Living Initiative Special Needs Populations (TCLI) by targeting those with chronic, unresolved, or complex physical, behavioral health, and social determinant needs. TCC will provide care planning as well as discharge and transition planning from Adult Care Homes, inpatient units, and detention centers with foundations in national evidence based and informed standards providing whole person care.

Requirements

Master’s degree in a human services field or licensure as an RN and one (1) year of relevant experience working directly with individuals with SED or SMI; OR Bachelor’s degree in a human services field or licensure as an RN and three (3) years of relevant experience working directly with individuals with SED or SMI.
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 and knowledge of peer support and experience working with individuals who are certified peer support specialists.

Responsibilities

Work collaboratively with licensed Clinicians, Registered Nurses, and Peer Support Specialists to ensure successful discharge/transition planning/post transition monitoring.
Provide care coordination/care management to assigned TCL individuals who may have identified needs with behavioral health, physical health, co-occurring, co-morbid or multi-morbid conditions.
Assess member’s needs who have transitioned into supportive housing to determine if additional support and services are needed for continued independent living.
Complete assessments as needed.
Ensure timely and accurate documentation of all planning and coordination efforts in multiple software platforms and State database systems.