[Remote] Transition Care Coordinator (Mid State)

Note: The job is a remote job and is open to candidates in USA. Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. They are seeking a Transition Care Coordinator to provide care coordination, treatment planning, assessment, and referral services for individuals with complex health needs. The role involves collaborating with a team to ensure successful discharge and transition planning for clients. Responsibilities 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 Skills 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 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 Experience and knowledge of peer support and experience working with individuals who are certified peer support specialists Benefits 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 Company Overview Trillium Health Resources is a local governmental agency for individuals with serious mental health, and intellectual disability services. It was founded in 1972, and is headquartered in Greenville, North Carolina, USA, with a workforce of 1001-5000 employees. Its website is