Role 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.

On a typical day, you might:

• 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.

Qualifications

• 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.

Requirements

• 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.

Benefits

• 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).
• 401k with 5% employer match and immediate vesting.
• Public Service Loan Forgiveness (PSLF) qualifying employer.
• Quarterly stipend for remote work supplies.