Transition of Care Coach LPN - Miami FL

This hybrid LPN Care Manager position is based in Miami, Florida, and requires approximately 50% local travel to hospitals and healthcare facilities to support members during critical transitions of care.

About the Role

The ideal candidate will have experience working with the Medicaid population, particularly managing complex, high-risk members with multiple medical, behavioral, and social needs. Candidates should possess strong clinical assessment, care coordination, communication, and problem-solving skills, along with the ability to manage a diverse caseload independently. Bilingual Spanish-English proficiency is preferred to effectively engage and support the diverse communities served throughout the Miami area.

Responsibilities

• Follows member throughout a 30-day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support.
• Works with participating ancillary providers, public agencies, or other service providers to ensure necessary services and equipment are in place for safe transition.
• Conducts face-to-face visits of all members while in the hospital and home visits for high-risk members post-discharge as needed.
• Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge.
• Educates and supports members focusing on seven primary areas (Transition of Care 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 assists members to address concerns.
• Facilitates interdisciplinary care team meetings (ICT) and collaboration.
• Provides consultation, resources, and recommendations to peers as needed.

40-50% local travel may be required (based upon state/contractual requirements).

Requirements

• At least 2 years of experience in healthcare, with at least 1 year of experience in hospital discharge planning, care management, or behavioral health setting, or equivalent combination of relevant education and experience.
• Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN).
• Clinical licensure and/or certification required only if mandated by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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.
• Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed—working with diverse populations, various personalities, and personal situations.
• Ability to work independently with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, with the ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving and critical-thinking skills.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office suite and other applicable software programs.

Preferred Qualifications

• Transitions of care sub-specialty certification and/or Certified Case Manager (CCM).
• Hospital discharge planning or home health experience.

Pay

Pay range: $24 - $46.81 per hour. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.