Transition of Care Coach - LOCAL TRAVEL REQUIRED

Molina Healthcare•Long Beach, WA

10d•Hybrid

About The Position

Molina Healthcare is hiring an experienced behavioral health professional to support 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. The position focuses on ensuring members have the services and resources needed after discharge and reducing hospital readmissions. Applicants should reside in Pierce County. The schedule is Monday through Friday, 8:00 AM to 5:00 PM PST, and mileage is reimbursed. The Transition of Care Coach supports care-transition activities and coordinates member discharge from a hospital to other settings. The coach follows members through a 30-day program beginning at hospital admission, helping ensure appropriate services are available at discharge and contributing to quality, cost-effective care.

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.
LVN or LPN. Clinical licensure or certification is required only when required by state contract, regulation, business operating model, or state board mandates; if licensed, the license must be active and unrestricted in the state of practice.
Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for work-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, and able to work independently with minimal supervision and self-motivation.
Ability to work in varied settings and adapt working style to diverse populations, personalities, and personal situations.
Responsive across communication channels and able to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Strong time-management and prioritization skills, including managing multiple projects and adapting to change.
Strong 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 sub-specialty certification and/or Certified Case Manager (CCM).
Hospital discharge planning or home health experience.

Responsibilities

Follow members throughout a 30-day program, from hospital admission through transitions to settings such as a nursing facility or private home, with the goal of reducing readmissions.
Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family or support networks to facilitate safe and appropriate transitions.
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 in place for a safe transition.
Conduct face-to-face visits with all members while they are 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 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, resources, and recommendations to peers as needed when applicable to behavioral health and social science education.
Complete local travel, which may be 40–50% based on state or contractual requirements.