Transition of Care Coach (BH Licensed)

Molina Healthcare•Long Beach, WA

14d•Hybrid

About The Position

Molina Healthcare is seeking a licensed behavioral health professional to support transition-of-care activities for Medicaid members admitted to psychiatric hospitals. The role coordinates member discharge from the hospital to other settings, ensuring appropriate services and resources are in place and helping reduce readmissions. The position is hybrid, combining work from a home office with travel to local hospitals to meet members and facility discharge teams. Applicants should reside in Thurston or Mason County, Washington. The stated schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. PST, and mileage is reimbursed. Local travel may account for 40–50% of the role, depending on state and contractual requirements. The coach follows members through a 30-day program beginning at hospital admission and continuing through transitions to settings such as a nursing facility or private home. The role involves collaboration with discharge planners, hospitalists, outpatient providers, facility staff, family and support networks, ancillary providers, public agencies, and other service providers. It includes hospital visits for all members and, as needed, home visits for high-risk members after discharge. The coach reassesses needs using the Coleman Care Transition model, provides education and support around the seven Transition of Care Pillars, identifies barriers, coordinates care, and facilitates interdisciplinary collaboration. The role also provides consultation and education to non-behavioral-health care managers. Acceptable Washington licenses listed in the posting include LICSW, LASW, LMHC, LMHCA, LMFT, ALICSW, ALASW, PhD, or PsyD. The required qualifications section also lists other behavioral-health credentials and requires an active, unrestricted license in the state of practice.

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 license in the state of practice. The required qualifications list LCSW, LMSW, APSW, CHES, LPC, LPCC, LMFT, PhD, or PsyD; the posting’s Washington-specific description lists LICSW, LASW, LMHC, LMHCA, LMFT, ALICSW, ALASW, 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.
Knowledge or experience in discharge planning and/or home health.
Demonstrated knowledge of community resources.
Proactive, detail-oriented approach.
Ability to work across varied settings and adapt to diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication channels 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 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 members’ families or support networks to ensure safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving and functional support, as well as medical and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to arrange services and equipment needed for a safe transition.
Conduct face-to-face visits with all members while they are 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, 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.
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; the posting indicates travel may be 40–50% depending on state and contractual requirements.