Transition of Care Coach - LOCAL TRAVEL REQUIRED

Molina Healthcare•Tacoma, WA

11d•$24 - $54•Hybrid

About The Position

The Transition of Care Coach provides support for care transition activities for Molina Medicaid members admitted to a psychiatric hospital. The role facilitates coordination from hospital admission through discharge and transition to other settings, working to ensure members have the services and resources needed after leaving the hospital and to reduce readmissions. It contributes to Molina’s strategy for quality, cost-effective member care. This hybrid position combines work from a home office with local travel to hospitals for face-to-face member visits and coordination with discharge teams. The coach follows members through a 30-day program beginning at hospital admission and may conduct home visits for high-risk members after discharge. Applicants should reside in Pierce County. The stated schedule is Monday through Friday, 8 AM–5 PM PST, with mileage reimbursement; local travel may account for 40–50% of the role.

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.
Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN); clinical licensure and/or certification is required only where required by state contract, regulation, business operating model, or state board mandate. 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 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 communication style when working with 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.
Strong time-management and prioritization skills, with the ability to manage multiple projects and adapt to change.
Strong problem-solving and critical-thinking skills.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office 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, including nursing facilities or private homes, with the goal of reducing readmissions.
Coordinate safe and appropriate transitions with hospital discharge planners, hospitalists, outpatient providers, facility staff, and members’ families or support networks.
Ensure members transition to settings with adequate caregiving, functional support, medical oversight, and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to ensure necessary services and equipment are available 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 and home- and community-based services, and advance directives.
Use motivational interviewing and Molina clinical guideposts to educate members, provide support, and motivate change during member 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.