Transition of Care Coach - LOCAL TRAVEL REQUIRED

Molina Healthcare•Long Beach, CA

11d•Hybrid

About The Position

Provides support for care transition activities and coordinates member discharge from a psychiatric hospital to other settings. The role follows members through a 30-day program beginning at hospital admission and continuing through transitions to a nursing facility, private home, or other settings. It focuses on ensuring members have appropriate services and resources at discharge and reducing readmissions, while contributing to quality and cost-effective care. This is a hybrid position based from a home office, with local travel to hospitals to meet members and discharge teams. Applicants should reside in Spokane or Spokane Valley. The schedule is Monday through Friday, 8 AM–5 PM PST, and mileage is reimbursed. Local travel may account for 40–50% of the role, depending 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.
LVN or LPN. Clinical licensure or certification is required only when mandated by state contract, regulation, business operating model, or state board licensing requirements; any required license must be active and unrestricted in the state of practice.
Valid and unrestricted driver’s license, reliable transportation, and adequate auto insurance for work-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 approach when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication methods 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 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.
Applicants should reside in Spokane or Spokane Valley.

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 from 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 members’ family or support networks to ensure safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving, functional support, medical oversight, and medication oversight.
Coordinate with participating ancillary providers, public agencies, and other service providers to arrange necessary services and equipment for a safe transition.
Conduct face-to-face visits with members in the hospital and, as needed, home visits with high-risk members after discharge.
Coordinate care and reassess member needs after discharge using the Coleman Care Transition model.
Educate and support members in medication management, use of a personal health record, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs or 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 coordination and assistance to address member concerns.
Facilitate interdisciplinary care team meetings and collaboration.
Provide consultation, resources, and recommendations to peers as needed when the coach has behavioral health and social science education.