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Transition Care Case Manager
2 months ago
JOB DESCRIPTION
Position Overview
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. This includes both behavioral health and long-term care for members with significant needs. HCS personnel strive to ensure that patients achieve desired health outcomes through quality care that is both medically appropriate and cost-effective, tailored to the severity of their condition and the care setting.
This role focuses on our Transition of Care program. We are looking for candidates with one of the following credentials: LSWAIC, LICSW, LMHC, or LMHCA. Strong computer proficiency and meticulous attention to detail are essential. The Transition of Care Coach will juggle multiple systems, engage with members and providers via phone, and document accurate and timely contact notes. Previous experience in discharge planning, collaboration with 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 preferred. Further details will be discussed during the interview process.
Work Environment: Remote position with 10% travel.
Work Schedule: Monday to Friday, 8:30 AM to 5:00 PM PST.
Preferred Location: Spokane WA - within a 25-mile radius for conducting facility visits.
KNOWLEDGE/SKILLS/ABILITIES
- Tracks member progress throughout a 30-day program, beginning at hospital admission and continuing through transitions to various settings, including nursing facilities and private homes, aiming to reduce readmissions.
- Ensures safe and suitable transitions by collaborating with hospital discharge planners and, as needed, with hospitalists, outpatient providers, facility staff, and family/support networks.
- Facilitates member transitions to environments with adequate caregiving and functional support, along with necessary medical and medication oversight. Works with ancillary providers (LTSS/HCSS, DME), public agencies, or other identified service providers to ensure essential services and equipment are available for a safe transition.
- Conducts 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.
- Coordinates care and reassesses member needs using the 2-day, 7-day, and 14-day post-discharge timelines as recommended by the Coleman Care Transitions Model.
- Educates and supports members focusing on seven primary areas (ToC Pillars): medication management, utilization of personal health records, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs, and advance directives.
- Employs motivational interviewing techniques and Molina clinical guidelines to educate, support, and inspire change during member interactions.
- Identifies barriers to care, provides care coordination, and assists members in addressing concerns.
- Facilitates interdisciplinary care team meetings and informal collaboration among the care team.
- Transition of Care Coaches in Behavioral Health and Social Science fields may offer consultation, resources, and recommendations to peers as necessary.
JOB 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 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 with the Care Transitions Intervention or similar models; background in discharge planning and/or home health.
Required License, Certification, Association
- If required by applicable state regulations, an LVN/LPN license in good standing.
- 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 or 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.
