Job Summary

Molina Healthcare Services (HCS) partners with members, providers, and multidisciplinary teams to deliver comprehensive care to members with high needs. We focus on facilitating a smooth transition of care across various settings, including behavioral health and long-term care, ensuring our patients receive quality, cost-effective medical support tailored to their individual requirements.

Key Responsibilities

Support members throughout a 30-day transition program starting at hospital admission and extending through various care settings, aiming to reduce readmissions.
Collaborate with hospital discharge planners, hospitalists, and outpatient providers to ensure safe transitions for members.
Ensure members move to environments with adequate support and oversight for caregiving, medications, and functional needs.
Coordinate with ancillary service providers and public agencies to ensure necessary services and equipment are in place for safe transitions.
Conduct face-to-face visits while members are in the hospital and follow-up home visits for high-risk members post-discharge.
Reassess members’ needs and coordinate care using the recommended post-discharge timeline.
Educate and support members on key health areas including medication management, personal health records, follow-up care, nutritional needs, and advance directives.
Utilize motivational interviewing and Molina’s clinical guideposts to foster engagement and behavioral change.
Identify and address barriers to care, providing essential coordination and assistance.
Facilitate interdisciplinary care team meetings to enhance collaboration and support.
Provide consultation and education to non-RN case managers regarding complex cases.
Conduct medication reconciliation as necessary.
Expect 5% local travel as part of this role.

Qualifications

Education: Graduate from an Accredited School of Nursing; Bachelor's Degree in Nursing preferred.

Experience: 1-3 years in hospital discharge planning or home health is required; 3-5 years preferred.

License: Active, unrestricted State Registered Nursing (RN) license is mandatory; must have a valid driver's license with a good record and be able to drive reliably.

Molina Healthcare provides a robust benefits and compensation package and is committed to being an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $30.37 - $59.21 / HOURLY *Compensation may vary based on geographic location, work experience, education, and/or skill level.

Registered Nurse Transition of Care Coach

Job Type