Transition of Care Coach (BH Licensed)

Molina Healthcare•Long Beach, FL

17h

About The Position

Provides support for care transition activities and coordinates member discharge from hospital admission to other settings. The role aims to ensure appropriate services are available at discharge and reduce member readmissions, while contributing to quality and cost-effective member care. The coach follows members through a 30-day program beginning at hospital admission and oversees transitions from acute care to settings such as a nursing facility or private home. The position includes face-to-face hospital visits and, as needed, home visits for high-risk members after discharge. Local travel may be required for 40–50% of the role, 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. Eligible credentials include LCSW, LMSW, APSW, CHES, LPC, LPCC, LMFT, PhD, or PsyD.
Valid, 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 across a variety of settings and adjust one’s approach when working with 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, with the 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 from 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’ 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 ensure necessary services and equipment are in place.
Conduct face-to-face visits with members in the hospital and home visits for 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 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.