Care Transitions Care Manager
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Job Description
Care manager guiding North Carolina members from institutional settings into integrated community care. Coordinating behavioral, physical, and social services for Trillium Health Resources.
Responsibilities:
- Provide in-reach and transition care management to members in institutional, congregate, or facility-based settings, including hospitals and inpatient units
- Educate members and guardians on navigating physical, behavioral, and social service systems and accessing informal/community resources
- Develop care plans based on national evidence-based and informed standards for whole-person care
- Guide and monitor providers regarding social determinant, medical, and other member needs
- Complete required documentation, paperwork, and software-platform tasks within designated timeframes
- Work on an interdisciplinary team addressing Olmstead Settlement and Tailored Plan functions
- Assess and monitor member health and safety, including during state emergencies or weather advisories
- Provide age- and developmentally appropriate education about integrated community-based care and available services
- Provide complex care management in compliance with NCQA and other regulatory/accreditation standards
- Offer opportunities to meet peers with SMI/SPMI diagnoses living, working, and receiving community services
- Identify, document, and address barriers to relocation to integrated community settings
- Engage residents of State Psychiatric Hospitals and ACHs regarding supportive housing, services, and community resources
Requirements:
- Must meet QP status
- Fully licensed by the NC governing board regulating Human Services professions; OR fully licensed RN licensed to practice in North Carolina by the NC Board of Nursing plus four years of full-time MH/DD/SA population experience; OR master's degree in a human service field plus one year of full-time MH/DD/SA experience; OR bachelor's degree in a human service field plus two years of full-time MH/DD/SA experience; OR bachelor's degree in another field plus four years of full-time MH/DD/SA experience
- Substance abuse professional alternatives require the stated supervised alcoholism and drug abuse counseling experience
- If serving members with LTSS needs, at least two years of prior LTSS and/or HCBS coordination, care delivery monitoring, and care management experience
- Must have a valid driver’s license
- Must reside within Trillium’s Northern Region: Bertie, Camden, Chowan, Currituck, Gates, Halifax, Hertford, Martin, Northampton, Pasquotank, Perquimans, and Warren counties
- Must be able to travel within catchment as required
- All candidates must pass a drug test as a condition of employment
Benefits:
- 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
- Flexible work schedules with some roles with management approval
- 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
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