Transition of Care Coach - LOCAL TRAVEL REQUIRED

Molina Healthcare•Long Beach, WA

10d•Hybrid

About The Position

Molina Healthcare is hiring an experienced, non-licensed behavioral health professional to support transition-of-care activities for Medicaid members admitted to psychiatric hospitals. This hybrid role combines work from a home office with local travel to hospitals to meet members and discharge teams. Applicants should reside in Spokane or Spokane Valley. The position operates Monday through Friday, 8:00 a.m. to 5:00 p.m. PST, and includes mileage reimbursement. The coach facilitates and coordinates member discharge from a hospital to other settings, helping ensure appropriate services and resources are in place and supporting the goal of reducing readmissions. Coaches follow members through a 30-day program beginning at hospital admission and provide oversight through transitions to settings such as nursing facilities or private homes. The role contributes to Molina’s strategy for quality, cost-effective member care.

Requirements

At least 2 years of experience in health care, 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.
Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). Clinical licensure or certification is required only where mandated by state contract, regulation, business operating model, or state board licensing requirements; any license held must be active and unrestricted in the state of practice.
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 of community resources.
Proactive and detail-oriented approach.
Ability to work in varied settings and adjust working style to 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 managing multiple projects and adapting 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, including nursing facility placement or a private home, 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, and medical and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to arrange necessary services and equipment for safe transitions.
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 the seven Transition of Care Pillars: medication management, personal health records, 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 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, resources, and recommendations to peers as needed when the coach has behavioral health or social science education.
Travel locally, potentially 40–50% of the time, based on state or contractual requirements.