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Transition Care Case Manager
2 months ago
POSITION SUMMARY
Molina Healthcare Services (HCS) collaborates with members, healthcare providers, and a multidisciplinary team to evaluate, facilitate, plan, and coordinate a comprehensive delivery of care across various settings, including behavioral health and long-term care, for individuals with significant healthcare needs.
This role is focused on our Transition of Care program. We are looking for candidates with licensure such as LSWAIC, LICSW, LMHC, or LMHCA. Strong computer proficiency and meticulous attention to detail are essential. The Transition of Care Coach will engage in multitasking across systems, communicate with members and providers via phone, and document accurate and timely contact notes. Previous experience in discharge planning, collaborating with healthcare providers, and navigating transportation and additional resources is required. The ability to work independently with a swift turnaround is crucial to ensure our members receive the necessary resources for discharge. Familiarity with the adult behavioral health system in Washington State is highly desirable. Further details will be discussed during the interview process.
This is a remote position with 10% travel required.
Work schedule: Monday to Friday, 8:30 AM to 5:00 PM PST.
Preferred location: Spokane WA, with a 25-mile radius for conducting facility visits.
KEY RESPONSIBILITIES
- Guide members through a 30-day program starting from hospital admission and continuing through transitions to various settings, including nursing facilities and private homes, aiming to reduce readmissions.
- Ensure safe and appropriate transitions by collaborating with hospital discharge planners and, as needed, with hospitalists, outpatient providers, facility staff, and family/support networks.
- Facilitate member transitions to settings with adequate caregiving and functional support, ensuring medical and medication oversight as required. Collaborate with ancillary providers and public agencies to ensure necessary services and equipment are in place for safe transitions.
- Conduct face-to-face visits with all members while hospitalized and home visits for high-risk members post-discharge.
- Local travel of 40-50% is required.
- Coordinate care and reassess member needs following the 2-day, 7-day, and 14-day post-discharge timeline recommended by the Coleman Care Transitions Model.
- Educate and support members focusing on seven primary areas: medication management, personal health record usage, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs, and advance directives.
- Utilize motivational interviewing techniques and Molina clinical guidelines to educate, support, and encourage change during member interactions.
- Identify barriers to care, provide care coordination, and assist members in addressing concerns.
- Facilitate interdisciplinary care team meetings and informal collaboration among care teams.
- Transition of Care Coaches in Behavioral Health and Social Science fields may offer consultation, resources, and recommendations to peers as needed.
QUALIFICATIONS
Required Education:
Any of the following:
- Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) program.
- Bachelor's or master's degree in social science, psychology, gerontology, public health, or social work.
Required Experience:
- 1-3 years in case management, disease management, managed care, or medical/behavioral health settings.
- Knowledge of or experience with the Care Transitions Intervention or similar models; background in discharge planning and/or home health.
Required License, Certification, Association:
- Active LVN/LPN license in good standing, if required by the state.
- If licensed, the license must be active, unrestricted, and in good standing.
- Must possess a valid driver's license with a good driving record and be able to drive within the applicable state or locality with reliable transportation.
Preferred Experience:
3-5 years in case management, disease management, managed care, or medical/behavioral health settings.
Preferred License, Certification, Association:
Any of the following:
- 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)
- One of the following licensures: LICSW, LSWAIC, LMHC, LMHCA
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $21.6 - $46.81 / HOURLY
*Actual compensation may vary based on geographic location, work experience, education, and/or skill level.
