Transition of Care Coach (BH Licensed)

Molina Healthcare•Long Beach, CA

15d•Hybrid

About The Position

The Transition of Care Coach supports care transitions for Molina Medicaid members admitted to psychiatric hospitals. This hybrid position combines work from a home office with travel to local hospitals to meet members and facility discharge teams. The role coordinates services and resources for safe discharge and aims to reduce hospital readmissions. Applicants should reside in Thurston or Mason County, Washington. The position follows members through a 30-day program beginning with hospital admission and continuing through transitions to other settings, including a nursing facility or private home. The coach coordinates care, reassesses needs after discharge, and contributes to quality, cost-effective member care. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. PST; mileage is reimbursed.

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 license in the state of practice. Listed qualifications include LCSW, LMSW, APSW, CHES, LPC, LPCC, LMFT, PhD, or PsyD. The posting’s introductory text also lists Washington licenses: LICSW, LASW, LMHC, LMHCA, LMFT, ALICSW, ALASW, PhD, or PsyD.
Valid, 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 adapt style when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across 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 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’ families 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 arrange necessary services and equipment.
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 post-discharge member needs using the Coleman Care Transition model.
Educate and support 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.
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.