Transition of Care Coach (BH Licensed) - Local Travel Required

Molina Talent Acquisition; Spokane (WA); Hybrid; USD 36,000 - 82,000; Full time

Job summary

Molina Healthcare in Spokane, WA is seeking a licensed behavioral health clinician to serve as Transition of Care Coach. This hybrid role requires local travel to hospitals, coordinating discharge planning and ensuring access to services after hospitalization, with a focus on reducing readmissions.

You will conduct home visits for high-risk members, collaborate with care teams, and educate members on medications, follow-up care, and community resources.

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 WA license (LICSW/LMSW/APSW/CHES/LPC/LPCC/LMFT/PhD/PsyD).
• Valid and unrestricted driver’s license and reliable transportation for travel requirements.
• Knowledge of CTI or similar transition models is preferred.

Responsibilities

• Support care transition activities during member discharge from hospital to other settings.
• Coordinate care with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family/support networks.
• Conduct face-to-face visits in hospital and home visits for high-risk members post-discharge.
• Educate members on medication management, follow-up care, and use of health records.
• Facilitate interdisciplinary care team meetings and coordinate with non-behavioral health managers.

Skills

Time management

Communication

Problem solving

Independence

Education

LICSW

LASW

LMHC

LMHCA

LMFT

PhD

PsyD

Tools

Microsoft Office Suite

Care Transitions Intervention (CTI)

Job description

Transition of Care Coach (BH Licensed) - Local Travel Required

Spokane, WA, United States and 1 more

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Job Description

JOB DESCRIPTION

Opportunity for a licensed Behavioral Health professional to work as a Transition of Care Coordinator with Molina’s Medicaid members who have been admitted to a psychiatric hospital. It is a hybrid position working from your home office and traveling to local hospitals to meet with those members and the discharge team at the facility. The focus is to ensure the members have all the services and resources they need when leaving the hospital and reducing hospital readmissions.

Applicants should reside in Spokane or the Spokane Valley; the acceptable Washington licenses are LICSW, LASW, LMHC, LMHCA, LMFT, ALICSW, ALASW, PhD or PsyD. Hours are M – F, 8 AM – 5 PM PST; reimbursement for mileage is included.

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.

• 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.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Job Info

• Job Identification 2039155
• Job Category Clinical
• Posting Date 09/29/2026, 09:12 PM
• Job Schedule Full time
• Locations Spokane, WA, United States Spokane Valley, WA, United States
• Salary Range $26.41 - $59.21 Hourly *Actual compensation may vary based on geographic location, work experience, education and/or skill level