Transition of Care Coach (BH Licensed)

Molina Healthcare•FL, FL

16h•$26 - $51

About The Position

Provides support for care transition activities and coordinates member discharge from hospital admission to other settings. The role strives to ensure members have appropriate services available at discharge and focuses on reducing readmissions while contributing to quality, cost-effective care. The coach follows members through a 30-day program beginning at hospital admission and continuing through transitions from acute care to settings such as a nursing facility or private home. The role collaborates with hospital discharge planners, hospitalists, outpatient providers, facility staff, families, and support networks to ensure safe transitions and adequate caregiving, functional, medical, and medication support. The coach works with ancillary providers, public agencies, and other service providers to arrange necessary services and equipment. The position includes face-to-face hospital visits and, when needed, home visits for high-risk members after discharge. It coordinates care and reassesses needs using the Coleman Care Transition model. The coach educates and supports members on medication management, use of a personal health record, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs and home- and community-based services, and advance directives. The role uses motivational interviewing and Molina clinical guideposts, assesses barriers to care, facilitates interdisciplinary care team collaboration, and provides consultation, recommendations, and education to non-behavioral health care managers. Local travel of 40–50% may be required based on state or contractual requirements.

Requirements

At least 2 years of healthcare experience, including at least 1 year in hospital discharge planning, care management, or a behavioral health setting, or an equivalent combination of relevant education and experience.
Active, unrestricted behavioral health clinician license in the state of practice. Listed credentials include LCSW, LMSW, APSW, CHES, LPC, LPCC, LMFT, or PhD/PsyD in psychology.
Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job-related travel, unless otherwise required by law.
Knowledge of or experience using the Care Transitions Intervention (CTI) or a similar model.
Background in discharge planning and/or home health.
Demonstrated knowledge of community resources.
Proactive and detail-oriented approach.
Ability to work in a variety of settings and adjust approach when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness in all forms of communication and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, ability to manage multiple projects simultaneously, and adaptability to change.
Excellent problem-solving and critical-thinking skills.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office suite and other applicable software programs.

Nice To Haves

Transitions of care subspecialty certification and/or Certified Case Manager (CCM).
Hospital discharge planning or home health experience.

Responsibilities

Follow members through a 30-day program beginning at hospital admission and oversee transitions from acute care to other settings, with the goal of reducing readmissions.
Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and families or support networks to facilitate safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving, functional support, and medical and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to ensure necessary services and equipment are in place for safe transitions.
Conduct face-to-face visits with members in the hospital and home visits with high-risk members after discharge as needed.
Coordinate care and reassess member needs after discharge using the Coleman Care Transition model.
Educate and support members on medication management, personal health records, follow-up care, warning signs of worsening conditions, nutrition, functional needs and home- and community-based services, and advance directives.
Use motivational interviewing and Molina clinical guideposts to educate, support, and motivate members during contacts.
Assess barriers to care and provide care coordination and assistance to address member concerns.
Facilitate interdisciplinary care team meetings and collaboration.
Provide consultation, recommendations, and education to non-behavioral health care managers as appropriate.
Travel locally as required; travel may be 40–50% based on state or contractual requirements.