Remote Care Transitions Specialist — Post-Discharge Coordination

Trillium Health Resources; North Carolina; Hybrid; USD 56,000 - 70,000; Full time

Benefits offered by this job

Health Insurance with no premium for (

Flexible Spending Accounts

24 days PTO + 12 holidays

401k with 5% employer match

Job summary

Trillium Health Resources seeks a Post Care Transitions Specialist to coordinate care planning and discharge processes for individuals with complex needs. The role emphasizes collaboration with licensed clinicians, RNs, and peer supports to ensure smooth transitions from inpatient or adult care settings.

You will develop plans, monitor progress, and document outcomes across multiple state systems, while supporting individuals in rural counties of the Mid State region.

Qualifications

• Fully licensed by the NC governing board regulating Human Services professions.
• RN license in NC with four years MH/DD/SA experience (optional path).
• Master’s degree in human services with one year MH/DD/SA experience.
• Bachelor’s degree in human services with two years MH/DD/SA experience.
• Bachelor’s degree in another field with four years MH/DD/SA experience.
• License/certification may be accepted as noted.
• Must have a valid driver’s license.
• Must reside within Trillium’s Mid State Region (Anson, Guilford, Montgomery, Randolph, Richmond).
• Must travel within catchment as required.

Responsibilities

• Provide care coordination and discharge/transition planning.
• Collaborate with licensed Clinicians, RNs, and Peer Support Specialists for discharge/transition planning.
• Assess member needs who transitioned into supportive housing to determine services needed.
• Complete assessments as needed.
• Ensure timely documentation of planning and coordination in software platforms and state databases.

Skills

Licensed by NC board

RN license in NC

Driver's license

Travel within catchment

Education

Master’s degree in human services

Bachelor’s degree in human services

Bachelor’s degree in any field

Job description

Trillium Health Resources seeks a Post Care Transitions Specialist to coordinate care planning and discharge processes for individuals with complex needs. The role emphasizes collaboration with licensed clinicians, RNs, and peer supports to ensure smooth transitions from inpatient or adult care settings.

You will develop plans, monitor progress, and document outcomes across multiple state systems, while supporting individuals in rural counties of the Mid State region.