Transition of Care Coach LICSW, LMFT, LMHC Remote with Field Travel Thurston or Mason County

Molina Healthcare; Everett (WA); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player seeks a compassionate Transition of Care Coach to enhance patient outcomes through effective care coordination. This role involves managing transitions for high-need members, ensuring they receive appropriate support and resources post-discharge. Ideal candidates will possess strong case management skills and relevant licensure, with a focus on collaboration with multidisciplinary teams. Join a mission-driven organization that values quality care and offers competitive benefits while making a meaningful impact in the lives of patients.

Qualifications

• WA state LICSW, LMFT, or LMHC licensure required.
• 1-3 years in case management or behavioral health settings preferred.

Responsibilities

• Manage transitions from acute settings to home or nursing facilities.
• Educate members on medication management and health records.

Skills

Case Management

Behavioral Health

Motivational Interviewing

Care Transitions Intervention

Education

Bachelor's/Master's in Social Sciences

Completion of LVN/LPN Program

Job description

Transition of Care Coach LICSW, LMFT, LMHC Remote with Field Travel Thurston or Mason County

Join to apply for the Transition of Care Coach LICSW, LMFT, LMHC role at Molina Healthcare.

Job Summary

Molina Healthcare Services (HCS) collaborates with members, providers, and multidisciplinary teams to assess, facilitate, plan, and coordinate integrated care across the continuum, including behavioral health and long-term care, for members with high needs. Our goal is to ensure patients achieve desired outcomes through quality, medically appropriate, and cost-effective care based on their severity of illness and service site.

Job Description

We seek candidates with WA state LICSW, LMFT, or LMHC licensure. Experience with inpatient settings and Medicaid is highly preferred. Bilingual candidates speaking Spanish are encouraged to apply. Details will be discussed during the interview.

This role is remote with field travel in Thurston or Mason County. Work schedule: Friday-Tuesday, 8:00 am-5:00 pm PST. WA LICSW, LMFT, or LMHC licensure is required.

Knowledge/Skills/Abilities

• Manage a 30-day program starting at hospital admission, overseeing transitions from acute settings to other environments, including nursing facilities and private homes, aiming to reduce readmissions.
• Coordinate safe and appropriate member transitions by collaborating with hospital discharge planners, outpatient providers, facility staff, and family/support networks.
• Ensure member transitions to settings with adequate caregiving, support, and medical oversight, working with ancillary providers and public agencies to ensure necessary services and equipment are in place.
• Conduct hospital face-to-face visits and high-risk member home visits post-discharge.
• Travel 40-50% locally.
• Use the Coleman Care Transitions Model to reassess member needs at 2, 7, and 14 days post-discharge.
• Educate and support members on medication management, health records, follow-up care, signs of worsening conditions, nutrition, functional needs, and advance directives.
• Apply motivational interviewing and Molina’s clinical guideposts to educate, support, and motivate members.
• Identify barriers to care, provide care coordination, and address member concerns.
• Facilitate interdisciplinary team meetings and informal care team collaboration.
• Behavioral health and social science ToC Coaches may offer peer consultation, resources, and recommendations.

Job Qualifications

Required Education

• Completion of an accredited LVN, LPN program, or a bachelor’s/master’s degree in social sciences, psychology, gerontology, public health, or social work.

Required Experience

• 1-3 years in case management, disease management, managed care, or behavioral/medical health settings.
• Knowledge or experience with Care Transitions Intervention or similar models; discharge planning and home health background preferred.

Required License, Certification, and Association

• Active, unrestricted WA LVN/LPN license if applicable, or other active licenses in good standing.
• Valid driver’s license with a good record and reliable transportation.

Preferred Experience

3-5 years in similar settings.

Preferred Licenses and Certifications

• Transitions of Care Sub-Specialty Certification
• LCSW, APSW, CCM, CHEP, LPC/LPCC, Respiratory Therapist, LMFT, or similar credentials.

Current Molina employees should apply via the intranet. Molina offers competitive benefits. We are an EOE M/F/D/V. Pay range: $24 - $53.83/hour. Actual pay may vary based on location, experience, education, and skills.