Complex Transitional Care Nurse (Mis-State)

Job description

Trillium Health Resources has a career opening for a Complex Transitional Care Nurse to join our team! The Complex Transitional Care Nurse is responsible for providing Complex Care Coordination targeting those with chronic, unresolved or complex physical, behavioral health and social determinant needs. This includes providing care planning with foundations in national evidence based and informed standards to do whole person care. The Complex Transitional Care Nurse completes required documentation/paperwork/tasks in a software platform according to timelines. Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval. 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) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook 401k with 5% employer match and immediate vesting Public Service Loan Forgiveness (PSLF) qualifying employer Quarterly stipend for remote work supplies

Responsibilities

• Complex care coordination to assigned individuals who may have identified needs with mental 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 members. 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. Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.

Requirements

• Required: Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse (RN) with a minimum of one (1) year experience as a Registered Nurse. 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. Preferred: Experience working with BH/MH/SU/IDD population. Knowledge of QM, UM procedures as well as experience in using data analytics for population health management. Experience assessing and coordinating care for members in adult care homes, family care homes, home residence or other settings.

About Trillium Health Resources

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. Why Work for Us? Trillium believes that empowering others begins with supporting our team. We offer our employees: A collaborative, mission-driven work environment Competitive benefits and work-from-home options for most positions Opportunities for professional growth in a diverse inclusive culture Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.