Complex Transitional Care Nurse

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) that manages serious mental health, substance use, traumatic brain injury, and intellectual/developmental disability services in North Carolina. Serving in 46 counties, we help individuals and their families strengthen well-being and build foundations for a healthy life. Join our team as we empower others to live their best lives by providing access to quality healthcare. We offer a challenging, engaging work environment where staff take home more than a paycheck. Every day, we see the results of our dedication – in the smiles of children on our accessible playgrounds and in the pride on the face of an adult cooking a meal for the first time. Working at Trillium Health Resources is more than just a job; it is an opportunity to make a direct impact on the communities we serve. At Trillium, we know that empowering others begins with supporting and developing our team. That’s why we offer competitive benefits and work-from-home flexibility so that our employees thrive outside of the office. We’re also committed to building a diverse, inclusive culture where all employees have the potential to grow professionally and personally.

Salary Range: $62,712.00 To $77,564.00 Annually Pay Plan Title: RN Working Title: Complex Transitional Care Nurse Cost Center: 92/Community Transition Position Number: 80983 FLSA Status: Exempt Posting Salary Range: $62,712 - $77,564 Office Location: Remote within Trillium’s South Central Region of our Catchment Area, which includes the North Carolina Counties: Carteret, Carven, Duplin, Jones, Lenoir, Onslow, Pender, Sampson, and Wayne. Trillium Health Resources has a career opening for a Complex Transitional Care Nurse! 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. Apply today to join this indispensable modern healthcare team!

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 discipline/teams (Care Coordinators, Clinicians, OT, COTA, Housing Specialists, Peers, etc.) 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. Complete Complex Transitional Care Nursing Assessment and other assessments as needed, to identify and link members to appropriate services/supports. Coordinate and participate in Integrated Care Teams. Review medical history and assessments. Provide education about all available services and natural and community supports, treatment options, diagnosis, etc. Coordinate linkage to needed psychological and physical health providers for evaluation and service implementation. Ensure the coordination of care with each individual’s primary care physician and/or other identified specialty physician.