Case Manager (Behavioral Health Transitions) - Kitsap/SalishBothell, Washington Job ID 2000145
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
• Follows member throughout a 30-day program that starts at hospital admission and continues its oversight through transitions from the acute setting to all other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating as needed or at the request of the member with hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required. Works with participating ancillary providers (LTSS/HCSS, DME), public agencies or other identified service providers to make sure necessary services and equipment are in place for a safe transition.
• Conducts face-to-face visits of all members while in the hospital; home visits of high risk members post discharge.
• 40-50% local travel required.
• Coordinates care and reassesses member's needs using the 2-day, 7-day and 14-day post-discharge timeline recommended by the Coleman Care Transitions Model.
• Educates and supports member focusing on seven primary areas (ToC 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 and informal ICT collaboration.
• ToC Coaches in Behavioral Health and Social Science fields may provide consultation, resources and recommendations to peers as needed.