M
Transition of Care Coach (BH Licensed)
Molina Healthcare
8 hours ago
Full-time
On-site
Portland, Oregon, United States
Social Worker
Job Summary
Provides support for care transition activities. Facilitates transitional care
processes and coordination for member discharge from hospital admission to all
other settings. Strives to ensure that best possible services are available to
members at time of hospital discharge, and focuses on goal to reduce member
readmissions. Contributes to overarching strategy to provide quality and
cost-effective member care.
Essential Job Duties
• Follows member throughout a 30 day program that starts at hospital admission
and continues oversight through transitions from acute setting to all other
settings, including nursing facility placement/private home, with the goal of
reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital
discharge planner, as well as collaborating with hospitalists, outpatient
providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional
support, as well as medical and medication oversight support.
• Works with participating ancillary providers, public agencies or other service
providers to make sure necessary services and equipment are in place for safe
transition.
• Conducts face-to-face visits of all members while in the hospital and, home
visits high-risk members post-discharge as needed.
• Coordinates care and reassesses member needs using the Coleman Care Transition
model post-discharge.
• Educates and supports member focusing on seven primary areas (Transition of
Care 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 (ICT) and collaboration.
• Provides consultation, recommendations and education as appropriate to
non-behavioral health care managers.
• 40-50% local travel may be required (based upon state/contractual
requirements).
Required Qualifications
• At least 2 years experience in health care, with at least 1 year of experience
in hospital discharge planning, care management or behavioral health setting, or
equivalent combination of relevant education and experience.
• Licensed behavioral health clinician to include: Licensed Clinical Social
Worker (LCSW), Licensed Master Social Worker (LMSW), Advanced Practice Social
Worker (APSW), Certified Health Education Specialist (CHES), Licensed
Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC),
Licensed Marriage and Family Therapist (LMFT, Doctor of Psychology (PhD or
PsyD). License must be active and unrestricted in state of practice.
• Valid and unrestricted driver's license, reliable transportation, and adequate
auto insurance for job related travel requirements, unless otherwise required by
law.
• Knowledge of or experience using the Care Transitions Intervention (CTI) or
similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed -
working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate
self-motivation.
• Responsive 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, and ability to focus on
multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/other applicable software program(s) proficiency.
Preferred Qualifications
• Transitions of care sub-specialty certification and/or Certified Case Manager
(CCM).
• Hospital discharge planning or home health experience.
To all current Molina employees: If you are interested in applying for this
position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina
Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Provides support for care transition activities. Facilitates transitional care
processes and coordination for member discharge from hospital admission to all
other settings. Strives to ensure that best possible services are available to
members at time of hospital discharge, and focuses on goal to reduce member
readmissions. Contributes to overarching strategy to provide quality and
cost-effective member care.
Essential Job Duties
• Follows member throughout a 30 day program that starts at hospital admission
and continues oversight through transitions from acute setting to all other
settings, including nursing facility placement/private home, with the goal of
reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital
discharge planner, as well as collaborating with hospitalists, outpatient
providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional
support, as well as medical and medication oversight support.
• Works with participating ancillary providers, public agencies or other service
providers to make sure necessary services and equipment are in place for safe
transition.
• Conducts face-to-face visits of all members while in the hospital and, home
visits high-risk members post-discharge as needed.
• Coordinates care and reassesses member needs using the Coleman Care Transition
model post-discharge.
• Educates and supports member focusing on seven primary areas (Transition of
Care 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 (ICT) and collaboration.
• Provides consultation, recommendations and education as appropriate to
non-behavioral health care managers.
• 40-50% local travel may be required (based upon state/contractual
requirements).
Required Qualifications
• At least 2 years experience in health care, with at least 1 year of experience
in hospital discharge planning, care management or behavioral health setting, or
equivalent combination of relevant education and experience.
• Licensed behavioral health clinician to include: Licensed Clinical Social
Worker (LCSW), Licensed Master Social Worker (LMSW), Advanced Practice Social
Worker (APSW), Certified Health Education Specialist (CHES), Licensed
Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC),
Licensed Marriage and Family Therapist (LMFT, Doctor of Psychology (PhD or
PsyD). License must be active and unrestricted in state of practice.
• Valid and unrestricted driver's license, reliable transportation, and adequate
auto insurance for job related travel requirements, unless otherwise required by
law.
• Knowledge of or experience using the Care Transitions Intervention (CTI) or
similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed -
working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate
self-motivation.
• Responsive 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, and ability to focus on
multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/other applicable software program(s) proficiency.
Preferred Qualifications
• Transitions of care sub-specialty certification and/or Certified Case Manager
(CCM).
• Hospital discharge planning or home health experience.
To all current Molina employees: If you are interested in applying for this
position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina
Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V