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at Molina Healthcare in Colbert, Washington, United States Job Description

JOB DESCRIPTION

Opportunity for an experienced, non-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. 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. Essential Job Duties

• 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 an To view full details and how to apply, please login or create a Job Seeker account