Transition of Care Coach, ED Discharge

Molina Healthcare • Henderson, NV • 3w ago

*** Qualified candidate must reside and be willing to travel in Washoe County OR Clark County NEVADA

JOB DESCRIPTION

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.

ADDITIONAL JOB FUNCTION:

The TOC Coach - ED Discharge Team, is dedicated to ensuring smooth transitions for patients from the hospital to the community, focusing on reducing readmissions and improving overall patient outcomes related to FUA/FUM measures. The TOC Coach - ED Discharge Team position will report to HCS and will have daily coordination and report outs with Quality Management as they are directly assigned to support the FUA/FUM withhold measures. The TOC Coach will be responsible for establishing and maintaining relationships with targeted Emergency Departments (ED) teams, the Human Behavior Institute (HBI) team, and maintain a consistent presence in Emergency Departments when permitted.

PROGRAM SPECIFICS:

Participating in initiatives to enhance the care transition process and reduce re-admissions. Will be directly responsible for supporting the FUA/FUM measures

Ensures safe and appropriate transitions by collaborating with the ED physicians, nurses and other Molina and external healthcare providers, 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. Conducting thorough assessments of patients' medical conditions, social needs, and potential discharge plans.

Conducts face-to-face visits of all members while in the hospital emergency department and in-patient settings.

75% local travel required.

-Arranging for necessary in-home services, follow-up appointments, family/primary support meetings, addressing health related social needs, and barriers to accessing care for members ready to leave the ED.

Providing education on behavioral health conditions, preventative care, managing co-occurring chronic conditions, medication adherence, accessing resources, addressing health related social needs, and healthy lifestyle choices.

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.

Provides daily reports to the Quality and HCS team on member encounters and outcomes.

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.

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.

Previous work experience in Emergency Department discharge

Preferred License, Certification, Association

Any of the following:

Licensed Alcohol and Drug Counselor

Peer Support Specialist

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)

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

This is a primarily field-based position, with approximately 75% of the day spent in the emergency department setting.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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 from posting based on geographic location, work experience, education and/or skill level.

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