Transition Care Manager

Transition Care Manager (Care Coach
2)

Humana Healthy Horizons in Virginia is seeking a Transition Care Manager (Care Coach
2) in the Central Region to assess members' needs and requirements to achieve and maintain optimal wellness through transitions in and out of various care settings.

Responsibilities include:

• Supporting and overseeing member transitions in and out of Virginia Medicaid programs and across care settings.
• Guiding members towards appropriate resources for their care.
• Coordinating with internal and external stakeholders to support safe and successful transitions.
• Assisting with planning and preparation for transitions and follow-up care.
• Working with the Primary Care Manager (PCM) and other departments to ensure continuity and coordination of care.
• Participating in Interdisciplinary Care Team (ICT) meetings and care planning activities.
• Ensuring the transfer and receipt of prior authorization decisions, utilization management data, and clinical information.
• Assisting with transitions from custodial settings to home and community-based settings.
• Collaborating with Housing Specialists and Social Workers for housing support and community resources.
• Requiring telephonic and in-person meetings within the assigned region to meet with long-term care members, hospital/rehab staff discharge planners, family members/POA's PCPs, and other health care professionals.
• Assessing and evaluating member's needs and requirements to establish a member specific care plan and coordinate services.
• Ensuring members are transitioning to the least restrictive setting to achieve and/or maintain optimal wellbeing by assessing their care needs.

Required Qualifications:

• An active, unrestricted Registered Nurse (RN) license in the Commonwealth of Virginia OR
• An active, unrestricted Licensed Practical Nurse (LPN) in the Commonwealth of Virginia OR
• Bachelor's degree in social work, psychology, counseling, gerontology, nursing or health & human services.

Required Requirements:

• Must reside in the Central Region of Virginia (Richmond, Glen Allen, Dinwiddie, Colonial Heights, Chester, Henrico) Will be traveling to the VCU area minimum 3 times per week.
• Two (2) years of prior experience in health care and/or case management.
• One (1) year of experience working directly with individuals who meet the Cardinal Care Priority Population criteria (Adults, pediatrics populations at risk for chronic medical conditions & high social needs).
• Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook.
• Ability to use a variety of electronic information applications/software programs including electronic medical records.
• Exceptional communication and interpersonal skills with the ability to build rapport with internal and external customers and stakeholders.
• Proven ability of critical thinking, organization, written and verbal communication and problem-solving skills.
• Ability to manage multiple or competing priorities in a fast-paced environment.
• This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Preferred Qualifications:

• Master's degree in social work, Psychology, Counseling, Gerontology, Nursing or Health & Human Services
• Applicable state license in field of study.
• Prior nursing home diversion or long-term care case management experience.
• Prior experience with Medicare & Medicaid recipients.
• Experience with electronic case note documentation and documenting in multiple computer applications/systems.
• Experience working with geriatric population.
• Experience with health promotion, coaching and wellness.
• Knowledge of community health and social service agencies and additional community resources.
• B…