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

About the job

Molina Healthcare is hiring a full-time licensed behavioral health professional as a transition of care coach in Spokane. The coach works with Medicaid members admitted to a psychiatric hospital, meeting them and the hospital discharge team so they leave with the services and resources they need and are less likely to be readmitted.

What you'll do

• Follow each member through a 30 day program that begins at hospital admission and continues as they move to a nursing facility, private home or other setting
• Work with the hospital discharge planner, hospitalists, outpatient providers, facility staff and family to make each transition safe
• Make sure the member goes to a setting with enough caregiving, functional support and medical and medication oversight
• Line up needed services and equipment with ancillary providers, public agencies and other service providers
• Visit every member in the hospital in person and make home visits to high-risk members after discharge as needed
• Reassess needs after discharge using the Coleman Care Transition model and teach members about the seven Transition of Care Pillars, such as medication management, follow-up care and advance directives
• Use motivational interviewing to support change, address barriers to care and coordinate help
• Run interdisciplinary care team (ICT) meetings and advise care managers who are not behavioral health specialists

What you need

• At least two years of health care experience, including at least one year in hospital discharge planning, care management or a behavioral health setting, or an equivalent mix of education and experience
• An active, unrestricted behavioral health license; the posting lists LCSW, LMSW, APSW, CHES, LPC, LPCC, LMFT, PhD or PsyD, and elsewhere names LMFT, LICSW, ALICSW, LASW, ALASW, LMHC, LMHCA, PhD or PsyD as the licenses it accepts in Washington
• Living in Spokane or Spokane Valley
• A valid driver's license, reliable transportation and adequate auto insurance
• Knowledge of or experience with the Care Transitions Intervention (CTI) or a similar model, and a background in discharge planning or home health
• Knowledge of community resources and proficiency with Microsoft Office

Preferred

• Transitions of care sub-specialty certification or Certified Case Manager (CCM)
• Past work in home health or hospital discharge planning

Schedule

• Full-time, 8 AM to 5 PM PST on weekdays
• Hybrid: work from a home office and travel to local hospitals, with 40-50% local travel possible

Benefits

• Mileage reimbursement