Healthcare - Healthcare Transitions Coach II
Work set-up:
Full Remote
Experience:
Mid-level (2-5 years)
Offer summary
Qualifications:
Completion of an accredited LVN, LPN, or a bachelor's/master's degree in social sciences, psychology, gerontology, public health, or social work., Minimum of 2 years experience in case management, care coordination, or related healthcare settings., Proficiency in MS Office/MS360, including Teams, Outlook, and Excel., Active, unrestricted license if required by state, with a valid driver's license and reliable transportation..Key responsibilities:
- Coordinate safe and appropriate patient transitions across healthcare settings.
- Interpret complex clinical data to identify members needing outreach and support.
- Respond to immediate clinical and non-clinical needs post-discharge, including medication management and resource linkage.
- Engage with members during a 90-day care program to prevent readmissions and facilitate recovery.
Job description
**clarification from the manager:
The requirement is ANY of the below; LVN, LPN, or a Bachelor's in one of the fields listed. An applicant with ANY ONE of these three meets this criterion.
Completion of an accredited Licensed Vocational Nurse (LVN) OR
Licensed Practical Nurse (LPN) Program OR
Bachelor's or master's degree in a social science, psychology, gerontology, public health, or social work.
REMOTE POSITIONS
MUST WORK Mountain Time
SCHEDULE: 8AM-5PM M-F
REQUIRES DUAL MONITORS AND DOCKING STATION
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. HCS staff work to ensure that Molina Members progress toward desired outcomes with quality care that is medically appropriate and cost-effective. The Transitions of Care Coordinator (TOCC) will engage Molina Members who are admitted to or discharged from any out- of- home setting, including but not limited to inpatient physical or behavioral health hospitals, nursing facilities, and rehabilitation centers. Successful candidate will support our members during this difficult transition period to improve outpatient healthcare thereby reducing the need for inpatient or out- of- home care.
DUTIES/RESPONSIBILITIES
Ensures safe and appropriate transitions by collaborating with the discharge planners, hospitalists, 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.
Interprets complex PowerBi data to identify and prioritize members in need of outreach due to admission or discharge.
Responds to and fulfills immediate clinical needs post- discharge needs, including but not limited to ensuring prescriptions are filled for both medications and durable medical equipment, assisting members with scheduling appropriate outpatient provider appointments, arranging transportation to and from scheduled medical appointments, and facilitating in- home services such as home health care.
Responds to and fulfills immediate non-clinical needs post- discharge needs, engaging with local resources for housing, local food pantries, transportation options, and other resources.
Responds to any behavioral health crisis encountered during typical contacts. With training and support from Molina's BH team, a TOCC who encounters a Member expressing suicidal thoughts or endorsing dangerous BH symptoms will be required to intervene by discussing safety planning, referring the Member to urgent care or phone support, and, if necessary, activating emergency services to ensure safety.
Engages with any Members who give birth in a hospital setting, ensuring timely healthcare delivery for both the new parents and baby.
Uses multiple clinical systems to obtain and utilize member/ patient data. TOCC will be required to find, read, and interpret clinical documentation such as hospital discharge summaries, then explain them to the member in a way that's easy to understand.
Completes clinical assessments of members per regulated timelines and determines who may qualify for in- person case management/ Care Coordination based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment. Complete referrals to Care Coordination, health education, or other Molina resources.
Follows member throughout a 90-day program that starts at hospital admission and continues through transitions from the acute setting to all other settings, including nursing facility placement and private home, with the goal of preventing additional admissions.
Coordinates care as needed during the 90- day program, and reassesses members' needs every 30 days after discharge, completing additional assessments, addressing any additional needs, and completing any necessary referrals to Care Coordination, health education, or other Molina resources.
Develops and implements a transition plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member's goals and prevent additional admissions.
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.
Participates in interdisciplinary care team (ICT) formal meetings and informal ICT collaboration, where the TOCC will be asked to provide input based on direct experience with a Member.
Protect Molina's member data by following HIPAA and HITECH laws, as well as Molina's policies regarding responsible use of sensitive data.
(??) Travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit
JOB QUALIFICATIONS
Required Education
Any of the following:
Completion of an accredited Licensed Vocational Nurse (LVN)
Licensed Practical Nurse (LPN) Program
Bachelor's or master's degree in a social science, psychology, gerontology, public health, or social work.
Minimum Required Experience:
2+ years in case management, care coordination, comprehensive community support services, disease management, managed care, or medical or behavioral health settings.
1+ years using MS Office/ MS360 including Teams, Outlook, and Excel
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.
1 year in Managed Care Transitions of Care (MCO TOC)
Experience using the Care Transitions Intervention or similar model background in discharge planning and/or home health.
Experience in behavioral health crisis intervention and suicide prevention.
1+ years using Microsoft SharePoint or PowerBi
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)
The requirement is ANY of the below; LVN, LPN, or a Bachelor's in one of the fields listed. An applicant with ANY ONE of these three meets this criterion.
Completion of an accredited Licensed Vocational Nurse (LVN) OR
Licensed Practical Nurse (LPN) Program OR
Bachelor's or master's degree in a social science, psychology, gerontology, public health, or social work.
REMOTE POSITIONS
MUST WORK Mountain Time
SCHEDULE: 8AM-5PM M-F
REQUIRES DUAL MONITORS AND DOCKING STATION
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. HCS staff work to ensure that Molina Members progress toward desired outcomes with quality care that is medically appropriate and cost-effective. The Transitions of Care Coordinator (TOCC) will engage Molina Members who are admitted to or discharged from any out- of- home setting, including but not limited to inpatient physical or behavioral health hospitals, nursing facilities, and rehabilitation centers. Successful candidate will support our members during this difficult transition period to improve outpatient healthcare thereby reducing the need for inpatient or out- of- home care.
DUTIES/RESPONSIBILITIES
Ensures safe and appropriate transitions by collaborating with the discharge planners, hospitalists, 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.
Interprets complex PowerBi data to identify and prioritize members in need of outreach due to admission or discharge.
Responds to and fulfills immediate clinical needs post- discharge needs, including but not limited to ensuring prescriptions are filled for both medications and durable medical equipment, assisting members with scheduling appropriate outpatient provider appointments, arranging transportation to and from scheduled medical appointments, and facilitating in- home services such as home health care.
Responds to and fulfills immediate non-clinical needs post- discharge needs, engaging with local resources for housing, local food pantries, transportation options, and other resources.
Responds to any behavioral health crisis encountered during typical contacts. With training and support from Molina's BH team, a TOCC who encounters a Member expressing suicidal thoughts or endorsing dangerous BH symptoms will be required to intervene by discussing safety planning, referring the Member to urgent care or phone support, and, if necessary, activating emergency services to ensure safety.
Engages with any Members who give birth in a hospital setting, ensuring timely healthcare delivery for both the new parents and baby.
Uses multiple clinical systems to obtain and utilize member/ patient data. TOCC will be required to find, read, and interpret clinical documentation such as hospital discharge summaries, then explain them to the member in a way that's easy to understand.
Completes clinical assessments of members per regulated timelines and determines who may qualify for in- person case management/ Care Coordination based on clinical judgment, changes in member's health or psychosocial wellness, and triggers from the assessment. Complete referrals to Care Coordination, health education, or other Molina resources.
Follows member throughout a 90-day program that starts at hospital admission and continues through transitions from the acute setting to all other settings, including nursing facility placement and private home, with the goal of preventing additional admissions.
Coordinates care as needed during the 90- day program, and reassesses members' needs every 30 days after discharge, completing additional assessments, addressing any additional needs, and completing any necessary referrals to Care Coordination, health education, or other Molina resources.
Develops and implements a transition plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member's goals and prevent additional admissions.
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.
Participates in interdisciplinary care team (ICT) formal meetings and informal ICT collaboration, where the TOCC will be asked to provide input based on direct experience with a Member.
Protect Molina's member data by following HIPAA and HITECH laws, as well as Molina's policies regarding responsible use of sensitive data.
(??) Travel of up to 40% may be required, depending on the complexity level of the assigned members, particular state-specific regulations, or whether the Case Manager position is located within Molina's Central Programs unit
JOB QUALIFICATIONS
Required Education
Any of the following:
Completion of an accredited Licensed Vocational Nurse (LVN)
Licensed Practical Nurse (LPN) Program
Bachelor's or master's degree in a social science, psychology, gerontology, public health, or social work.
Minimum Required Experience:
2+ years in case management, care coordination, comprehensive community support services, disease management, managed care, or medical or behavioral health settings.
1+ years using MS Office/ MS360 including Teams, Outlook, and Excel
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.
1 year in Managed Care Transitions of Care (MCO TOC)
Experience using the Care Transitions Intervention or similar model background in discharge planning and/or home health.
Experience in behavioral health crisis intervention and suicide prevention.
1+ years using Microsoft SharePoint or PowerBi
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)
Required profile
Experience
Level of experience: Mid-level (2-5 years)
Spoken language(s):
English
Check out the description to know which languages are mandatory. Other Skills
- Microsoft Excel
- Microsoft Office
- Microsoft Outlook
- Collaboration
- Communication
- Social Skills
- Problem Solving
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