Transition of Care Coach Remote (Must have CA LVN/LPN)

Molina Healthcare of California is hiring a Transition of Care Coach LVN/LPN . This role is remote; however, candidates must have a valid and unrestricted California LVN/LPN licensure. The hours will be Monday through Friday from 8am to 5pm Pacific Standard Time. Must be an LVN/LPN with an active, unrestricted California licensure Monday through Friday from 8am to 5pm Pacific Standard Time Solid and above average computer skills. Able to navigate MS Outlook/Excel/Word and learn Windows based software. Point Click Care, Epic, etc… Managed care experience. Experience with care coordination and discharge planning. Familiarity with community-based organizations and social service resources. Knowledge of social determinants of health. Bilingual skills (desired, not required) (Spanish, Vietnamese, Mandarin, or other prevalent languages preferred). Experience working with high-risk or vulnerable populations. 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.
• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.
• Facilitates interdisciplinary care team meetings (ICT) and collaboration.
• Transition of care coaches with behavioral health and social science education may provide consultation, resources and recommendations to peers as needed.
• 40-50% local travel may be required (based upon state/contractual requirements).

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 Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. 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. 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. Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. Microsoft Office suite/other applicable software program(s) proficiency. 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 Key Words: Discharge Planning, Home Health, MCG Guidelines, Social Services, Health Care Navigator, Discharge Planner, Care Manager, Case Manager, LVN, LPN, Licensed Vocational Nurse, Licensed Practical Nurse, Continuity of Care, Transition of Care / Transitional Care, Interdisciplinary Collaboration / Multidisciplinary Team, Comprehensive Patient Assessment, Acuity & Functional Assessment, Medication Reconciliation, Patient & Caregiver Education, Post-Acute & Resource Coordination, Durable Medical Equipment (DME), Home Health Care / Home Care Services, Skilled Nursing Facility (SNF) Placement, Inpatient Rehabilitation / Long-Term Acute Care (LTAC), Community Resource Linkage / Utilization, Transportation & Follow-up Scheduling, Compliance, Payors & Quality Metrics, Medicare / Medicaid Guidelines, Condition of Participation (CoP), Readmission Prevention / Reducing 30-Day Readmissions, Utilization Review (UR) / Case Management, Insurance Verification & Payor Source Management, HIPAA Compliance & Confidentiality