Transition of Care Coach (BH Licensed)

Molina Healthcare•Long Beach, CA

About The Position

Provides support for care transition activities and facilitates transitional care processes and coordination for member discharge from hospital admission to other settings. The role strives to ensure members have access to the best possible services at hospital discharge and focuses on reducing readmissions, while contributing to quality and cost-effective member care. The coach follows members through a 30-day program beginning at hospital admission and provides oversight during transitions from acute care to other settings, including nursing facility placement or a private home. The position collaborates with hospital discharge planners, hospitalists, outpatient providers, facility staff, and members’ families or support networks to promote safe and appropriate transitions. It assesses caregiving, functional, medical, and medication oversight needs and coordinates services and equipment required for a safe transition. The role includes face-to-face hospital visits and, as needed, post-discharge home visits for high-risk members. It coordinates care and reassesses member needs using the Coleman Care Transition model. The coach educates and supports members on medication management, personal health records, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs and home- and community-based services, and advance directives. The position uses motivational interviewing and Molina clinical guideposts, assesses barriers to care, facilitates interdisciplinary care team meetings, and provides consultation 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 health care 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, PhD, or PsyD.
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 varied settings and adjust style 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, including the ability to manage multiple projects and adapt 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 family or support networks to ensure 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 a safe transition.
Conduct face-to-face visits with members in the hospital and, as needed, home visits for high-risk members after discharge.
Coordinate care and reassess member needs after discharge using the Coleman Care Transition model.
Educate and support members in the seven Transition of Care Pillars: medication management, use of a personal health record, follow-up care, signs and symptoms of worsening condition, nutrition, functional needs and home- and community-based services, and advance directives.
Use motivational interviewing and Molina clinical guideposts to educate, support, and motivate change during member 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, potentially 40–50% of the time, based on state or contractual requirements.