Transition Care Coordinator (Mid-State)
About The Position
Trillium Health Resources is seeking a Transition Care Coordinator (TCC) to join their team. The TCC will be responsible for providing comprehensive care coordination, including treatment planning, assessment, monitoring, education, and referral/linking services. This role specifically targets individuals identified in the Transitions to Community Living Initiative Special Needs Populations (TCLI) who have chronic, unresolved, or complex physical, behavioral health, and social determinant needs. The TCC will focus on care planning, as well as discharge and transition planning from Adult Care Homes, inpatient units, and detention centers, adhering to national evidence-based and informed standards for 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.
- Relevant experience is defined as experience working with individuals with behavioral/mental health, substance use, and/or I/DD.
- 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.
Benefits
- Competitive benefits
- Work-from-home options for most positions
- A collaborative, mission-driven work environment
- Opportunities for professional growth in a diverse inclusive culture
- 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
