Care Transitions Coach - Hospital Discharge & Care Coordination

Molina Healthcare Inc; Lexington (KY); On-site; USD 60,000 - 85,000; Full time

Job summary

Molina Healthcare is seeking a care transition supporter to facilitate hospital discharge planning and coordination to multiple settings, reducing readmissions. The role emphasizes collaboration among hospital staff, providers, and family, with a focus on safe transitions and quality, cost-effective member care.

Candidates bring at least 2 years in health care and active behavioral health licensure. Travel expectations and proficiency with standard software are required.

Qualifications

• At least 2 years experience in health care with hospital discharge planning, care management or behavioral health setting.
• Licensed behavioral health clinician with active state license.
• Valid driver’s license and reliable transportation for travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.

Responsibilities

• Follows member through 30 day program from hospital admission and transitions to other settings to reduce readmissions.
• Collaborates with discharge planners, hospitalists, outpatient providers, facility staff, and family.
• Ensures safe transitions with adequate caregiving and medical oversight.
• Coordinates with ancillary providers and public agencies to arrange services and equipment.
• Performs face-to-face hospital visits and home visits for high-risk members post-discharge.
• Reassesses needs using Coleman Care Transition model post-discharge.
• Educates member on medication management, health records, follow-up care, and other pillars.
• Uses motivational interviewing to support change.
• Identifies barriers to care and facilitates care coordination.
• Facilitates interdisciplinary care team meetings.
• Provides guidance to non-behavioral health care managers.
• 40-50% local travel may be required.

Skills

Health Care Experience

Discharge Planning

Care Management

Behavioral Health

Driver's License

Time Management

Communication Skills

MS Office Proficiency

Education

Licensed Clinician License (LCSW/LMSW/APSW/LPC/LPCC/LMFT/PhD/PsyD)

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a care transition supporter to facilitate hospital discharge planning and coordination to multiple settings, reducing readmissions. The role emphasizes collaboration among hospital staff, providers, and family, with a focus on safe transitions and quality, cost-effective member care.

Candidates bring at least 2 years in health care and active behavioral health licensure. Travel expectations and proficiency with standard software are required.