Registered Nurse - Care Transition Coach

Job Summary

As a Care Transition Coach, you will play a pivotal role in supporting our members during their transition from hospital to home or other care settings. Your efforts will be directed towards ensuring these transitions are seamless and effective, ultimately aiming to reduce readmission rates and improve overall quality of care.

Essential Responsibilities

• Provide consistent support for members during a 30-day care transition program, beginning at hospital admission and continuing through to their new living environment.
• Collaborate with hospital discharge planners, hospitalists, outpatient providers, and family networks to ensure a safe and smooth transition for our members.
• Assess and ensure that all necessary caregiving support and medical oversight is in place for each member after discharge.
• Work with diverse ancillary providers and agencies to arrange necessary services and equipment for safe transitions.
• Conduct face-to-face visits with members while hospitalized and perform home visits for high-risk members after discharge as needed.
• Utilize the Coleman Care Transition model to coordinate care and reassess member needs post-discharge.
• Educate members on crucial topics, including medication management, follow-up care, and advance directives, using motivational interviewing techniques.
• Identify and address barriers to care, facilitating coordination and providing support to enhance members' access to services.
• Organize interdisciplinary care team meetings to foster collaboration among healthcare professionals.
• Offer guidance and education to non-behavioral health care managers as necessary.
• Be prepared for 40-50% local travel, compliant with state and contractual obligations.

Required Qualifications

• A minimum of 2 years of healthcare experience, including 1 year in hospital discharge planning, care management, or a behavioral health setting.
• Active and unrestricted Registered Nurse (RN) license in your state of practice.
• Valid driver’s license and reliable transportation for travel requirements.
• Knowledge or experience with Care Transitions Intervention (CTI) or equivalent models.
• Background in discharge planning or home health preferred.
• Strong knowledge of community resources.
• Exceptional detail orientation and proactive mindset.
• Able to adapt communication styles for diverse populations and varied personal situations.
• Ability to work independently and maintain self-motivation with minimal supervision.
• Effective communication skills, with calmness under pressure.
• Strong professional relationship-building abilities.
• Excellent time management, problem-solving, and critical-thinking skills.
• Proficient in Microsoft Office and other relevant software applications.

Preferred Qualifications

• Certification in transitions of care or as a Certified Case Manager (CCM).
• Experience in hospital discharge planning and home health.

As a valued team member, you can expect a competitive benefits and compensation package with Molina Healthcare. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 - $59.21 / HOURLY. Actual compensation may vary based on geographic location, experience, education, and skill level.