**Become a part of our caring community and help us put health first** Humana Healthy Horizons in Virginia is seeking Transition Coordinators (Care Coach 2) to assess members’ needs and requirements to achieve and maintain optimal wellness through transitions in and out of various care settings. The Transition Coordinator (Care Coach 2) work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. + 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 (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 (Care Coach 2) shall meet **ALL** of the following requirements: + **Must reside in the Commonwealth of Virginia or within a 40-mile radius from Virginia in a bordering state/district (Washington DC, MD, WV, KY, TN & NC).** + 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. + Must be able to travel throughout Medicaid regions in the Commonwealth of Virginia. + 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 field position where employees perform their core duties at non-company locations, such as providing services at business partner facilities or prospects' and members' homes. + **Travel:** 35 - 50% 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 with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. **WAH Internet Statement** To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. **Interview Format** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $59,300 - $80,900 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. **About us** Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.