Care Transitions Specialist: Discharge & Coordination

Molina Healthcare; Jackson (MS); On-site; USD 33,000 - 70,000; Full time

Job summary

Molina Healthcare is seeking a skilled Care Transition Specialist to support discharge planning and coordination for members. You will follow patients through a 30‑day transition, collaborating with hospital teams, providers, and family to reduce readmissions and ensure safe, effective handoffs.

The role requires health care experience, licensed behavioral health credentials, and strong communication and organizational skills to manage multiple priorities and travel locally as needed.

Qualifications

• At least 2 years in health care with 1 year in discharge planning, care management or behavioral health.
• Licensed behavioral health clinician with active license in state of practice.
• Valid driver’s license, reliable transportation, and adequate auto insurance for travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work independently with minimal supervision and motivation.
• Strong time-management and prioritization skills.
• Excellent problem-solving and critical-thinking skills.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office.

Responsibilities

• Follows member through a 30 day program from hospital admission to transition.
• Collaborates with discharge planners, hospitalists, providers, facility staff and family.
• Ensures safe transitions with adequate caregiving and medical oversight.
• Coordinates with ancillary providers and community services to arrange needed care.
• Performs face-to-face hospital visits and post-discharge home visits for high-risk members.
• Reassesses needs using the Coleman Care Transition model after discharge.
• Educates members on seven Transition of Care Pillars: meds, records, follow-up, signs, nutrition, functional needs, community services.
• Uses motivational interviewing and Molina guidelines to educate and motivate change.
• Assesses barriers to care and provides care coordination to address concerns.
• Facilitates interdisciplinary care team meetings and collaboration.
• Provides consultation to non-behavioral health care managers.
• Travel 40-50% locally as required.

Skills

Care transition

Discharge planning

Behavioral health

Licensed clinician

Driver's license

CTI knowledge

Microsoft Office

Communication

Time management

Problem solving

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a skilled Care Transition Specialist to support discharge planning and coordination for members. You will follow patients through a 30‑day transition, collaborating with hospital teams, providers, and family to reduce readmissions and ensure safe, effective handoffs.

The role requires health care experience, licensed behavioral health credentials, and strong communication and organizational skills to manage multiple priorities and travel locally as needed.