Transition Care Manager

About this role

Become a part of our caring community   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. The Transition Care Manager (Care Coach 2) work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. This position will require travel to Central hospitals 3 times per week minimum.

• Supports and oversees the initial and ongoing member transitions in and out of the various Virginia Medicaid programs, and across care settings to prevent unplanned or unnecessary readmissions, ED visits, or adverse outcomes. • Guides members towards resources appropriate for their care. • Coordinates with internal and external stakeholders involved with the member’s care to support safe and successful transitions. • Assists with the planning and preparation for transitions and the follow-up care after transitions are completed.  • Works with the Primary Care Manager (PCM) and/or other member-focused departments of the plan to ensure continuity and coordination of care and member and provider communication. • Participates in Interdisciplinary Care Team (ICT) meetings and care planning activities. • Ensures the transfer and receipt of all outstanding prior authorization decisions, utilization management data, and clinical information such as prevention and wellness programs(s), care management and complex case management notes.  • Assists with transitions from the custodial setting to the home and community-based setting. • Collaborates with the Housing Specialist when the member needs housing support and the Social Worker with community resources and health related social needs. • Requires telephonic and in-person meetings within assigned region to meet with the long-term care members, hospital/rehab staff discharge planners, family members/POA's PCPs, and other health care professionals in order to prevent custodial placements when possible. • Assesses and evaluates member's needs and requirements to establish a member specific care plan and coordinates services. • Ensures members are transitioning to the least restrictive setting to achieve and/or maintain optimal wellbeing by assessing their care needs.

Use your skills to make an impact   Required Qualifications Transition Coordinators/Transition Care Managers (Care Coach 2) shall meet one (1) of the following 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.

Transition Coordinators/Transition Care Managers (Care Coach 2) shall meet ALL of the following 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. • Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See "Additional Information" for more information.

Additional Information • Workstyle: Field - This is a combination of remote and field position where employees perform their core duties at non-company locations, such as providing services at in-patient settings • Travel: 50 - 75% field interactions with members, and their families and providers. May need to attend onsite meetings occasionally in Humana Healthy Horizons office in Glen Allen, VA. • Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST). • Language Assessment Statement: Any Humana associate who speaks

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