Transition of Care Coach (BH Licensed)

Molina Healthcare•Long Beach, KY

About The Position

Provides support for care transition activities and coordinates the transition of members from hospital admission to other care settings. The role seeks to ensure members have appropriate services available at discharge and to reduce readmissions, while contributing to quality and cost-effective care. The coach follows members through a 30-day program beginning at hospital admission and continues oversight as they transition to settings such as a nursing facility or private home. The position collaborates with hospital discharge planners, hospitalists, outpatient providers, facility staff, families, and support networks to arrange safe transitions with adequate caregiving, functional, medical, and medication support. The role includes face-to-face hospital visits, post-discharge home visits for high-risk members as needed, reassessment and care coordination using the Coleman Care Transition model, and education based on the Transition of Care Pillars. The coach also addresses 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 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 clinician license in the state of practice. Accepted 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, with the 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.
Responsive communication skills and the 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.

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, functional support, and medical and medication oversight.
Coordinate with participating ancillary providers, public agencies, and other service providers to arrange services and equipment needed for a safe transition.
Conduct face-to-face visits with members 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, personal health records, 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 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.