[Hiring] Transition Coordinator @TRILLIUM HEALTH RESOURCES

Role Description

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.

On a typical day, you might:

• 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.

Qualifications

• 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 75 miles of Wayne County, North Carolina.
• Must be able to travel within catchment as required.

Requirements

• Experience and knowledge of peer support and experience working with individuals who are certified peer support specialists.

Benefits

• Typical working hours: 8:30 am – 5:00 pm
• 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