Transition of Care Coach: Central llinois
Molina Healthcare Rockford, Illinois; Joliet, Illinois; Aurora, Illinois; Naperville, Illinois; Chicago, Illinois Job ID 2031066**Illinois residents preferred. This will be a primarily remote position with potential for very limited or no travel. This will be coverage for Region 2 (Central IL- Adams, Brown, Calhoun, Cass, Champaign, Christian, Clark, Coles, Cumberland, Dewitt, Douglas, Edgar, Ford, Greene, Hancock, Iroquois, Jersey, Livingston, Logan, Macon, Macoupin, Mason, McDonough, Mclean, Menard, Montgomery, Morgan, Moultrie, Piatt, Pike, Sangamon, Schuyler, Scott, Shelby, Vermilion),
JOB DESCRIPTION
Job Summary
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.
KNOWLEDGE/SKILLS/ABILITIES
- 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.
- 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.
JOB QUALIFICATIONS
Required Education
Any of the following:
- Completion of an accredited Licensed Vocational Nurse (LVN)
- Licensed Practical Nurse (LPN) Program
- Bachelor's or master’s degree in a social science, psychology, gerontology, public health or social work.
Required Experience
- 1-3 years in case management, disease management, managed care or medical or behavioral health settings.
- Knowledge of or experience using the Care Transitions Intervention or similar model; background in discharge planning and/or home health.
Required License, Certification, Association
If licensed, license must be active, unrestricted and in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
Preferred Experience
3-5 years in case management, disease management, managed care or medical or behavioral health settings.
Preferred License, Certification, Association
Any of the following:
- Licensed Clinical Social Worker (LCSW)
- Advanced Practice Social Worker (APSW)
- Licensed Professional Counselor (LPC/LPCC)
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $21.6 - $46.81 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 04/01/2025ABOUT OUR LOCATION
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