Transition of Care Coach, LTSS; RN - Local

JOB DESCRIPTION

We are seeking TX licensed Registered Nurses who live in either the Dallas, Fort Worth, or Houston service delivery areas.

This RN will act as a Transition of Care Coach supporting our TX Medicaid members who have recently been admitted to a local hospital. The TOCC will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient.

Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.

TRAVEL in the field to designated hospitals in the local service delivery area to meet with the members. Mileage is reimbursed as part of our benefit package.

Schedule:

Monday through Friday 8:00AM to 5:00PM CST (No weekends, no nights, no holidays, no call.)

Job Summary

Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Completes comprehensive member assessments within regulated timelines, including in-person home visits as required.

• Facilitates comprehensive waiver enrollment and disenrollment processes.

• Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals.

• Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.

• Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care.

• Assesses for medical necessity and authorizes all appropriate waiver services.

• Evaluates covered benefits and advises appropriately regarding funding sources.

• Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration.

• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.

• Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns.

• Identifies critical incidents and develops prevention plans to assure member health and welfare.

• May provide consultation, resources and recommendations to peers as needed.

• Care manager RNs may be assigned complex member cases and medication regimens.

• Care manager RNs may conduct medication reconciliation as needed.

• 25-40% estimated local travel may be required (based upon state/contractual requirements).

Required Qualifications

• At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience.

• Registered Nurse (RN). License must be active and unrestricted in state of practice.

• Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law.

• Ability to operate proactively and demonstrate detail-oriented work.

• Demonstrated knowledge of community resources.

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