Transition of Care Coach

Job Summary

Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

This position will be supporting our Transition of Care program. We are seeking a candidate with one of the following licensures: LSWAIC, LICSW, LMHC, or LMHCA. Excellent computer skills and attention to detail are very important. The ToC Coach will multitask between systems, talk with members/providers on the phone, enter accurate and timely contact notes. Previous experience with discharge planning, collaborating with Providers, transportation and additional resources. Must be able to work independently with a quick turn over to ensure our members receive the adequate resources for discharge. Candidates with Managed Care Organization (MCO) and the Medicaid behavioral health system in Washington State are highly preferred. Further details to be discussed during our interview process.

Knowledge/Skills/Abilities

Follows member throughout a 30-day program that starts at hospital admission and continues its oversight through transitions from the acute setting to all other settings, including nursing facility placement and private home, with the goal of reduced readmissions. Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating as needed or at the request of the member with hospitalists, outpatient providers, facility staff, and family/support network. Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required. Works with participating ancillary providers (LTSS/HCSS, DME), public agencies or other identified service providers to make sure necessary services and equipment are in place for a safe transition. Conducts face-to-face visits of all members while in the hospital; home visits of high-risk members post discharge. 40-50% local travel required. Coordinates care and reassesses member's needs using the 2-day, 7-day and 14-day post-discharge timeline recommended by the Coleman Care Transitions Model. Educates and supports member focusing on seven primary areas (ToC Pillars): medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and/or Home and Community-based Services, and advance directives. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. Facilitates interdisciplinary care team meetings and informal ICT collaboration. ToC Coaches in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed.

Job Qualifications

Required Education

• Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program
• Bachelor's or master’s degree in a social science, psychology, gerontology, public health or social work.

Required Experience

• 1-3 years in case management, disease management, managed care or medical or behavioral health settings.
• Knowledge of or experience using the Care Transitions Intervention or similar model; background in discharge planning and/or home health.

Required License, Certification, Association

• If required by applicable State, an LVN/LPN license in good standing.
• Otherwise, if licensed, license must be active, unrestricted and in good standing.
• Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Experience

• 3-5 years in case management, disease management, managed care or medical or behavioral health settings.

Preferred License, Certification, Association

• Transitions of Care Sub-Specialty Certification
• Licensed Clinical Social Worker (LCSW)
• Advanced Practice Social Worker (APSW)
• Certified Case Manager (CCM)
• Certified in Health Education and Promotion (CHEP)
• Licensed Professional Counselor (LPC/LPCC)
• Respiratory Therapist
• Licensed Marriage and Family Therapist (LMFT)

Pay Range: $24 - $53.83 / HOURLY