Transition Care Coordinator

Trillium Health Resources is a local governmental agency (LME/MCO) in North Carolina that manages serious mental health, substance use, and intellectual/developmental disability services. 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.

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 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.

Work collaboratively with licensed Clinicians, Registered Nurses, and Peer Support Specialists to ensure successful discharge/transition planning/post transition monitoring. Provides 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. Completes Care Management, Comprehensive Assessment and other assessments Ensure timely and accurate documentation of all transition planning/post transition planning and coordination efforts in Trillium Health Resources software platform and multiple State database systems.