Impactful RN: Care Transitions Coach for Safe Discharges

Molina Talent Acquisition; Detroit (MI); Vor Ort; USD 65.000 - 90.000; Vollzeit

Zusammenfassung

Molina Healthcare is seeking a Care Transition Nurse/Coordinator to support members in Michigan’s Medicare and Integrated Duals programs, guiding them from hospital admission through post-acute settings to reduce readmissions.

Responsibilities include coordinating with discharge planners, hospital teams, and families; conducting in-person visits; educating members on medication management, follow-up care, and community resources; and applying the Coleman Care Transition model to ensure safe,

Qualifikationen

• At least 2 years in health care, with at least 1 year in discharge planning, care management or behavioral health setting.
• RN license active and unrestricted in state of practice.
• Valid driver's license, reliable transportation and adequate auto insurance for job-related travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented, able to work independently.
• Excellent time-management, prioritization and communication skills.

Aufgaben

• Follows member through a 30 day program from hospital admission to transitions to other settings with aim of reducing readmissions.
• Collaborates with discharge planner, hospitalists, outpatient providers, facility staff and family for safe transitions.
• Ensures transitions with adequate caregiving, medical and medication oversight.
• Coordinates with ancillary providers and public agencies to arrange services and equipment.
• Conducts face‑to‑face hospital visits and post-discharge home visits for high‑risk members.
• Reassesses needs using the Coleman Care Transition model post-discharge.
• Educates on seven transition pillars: meds, personal health record, follow-up, warning signs, nutrition, functional needs, and home/community services.
• Uses motivational interviewing and Molina clinical guideposts to motivate change.
• Identifies barriers to care and provides care coordination to address concerns.
• Facilitates ICT meetings and interdisciplinary collaboration.
• Provides consultation and education to non-behavioral health care managers as appropriate.

Kenntnisse

Microsoft Office

Communication

Time management

Self-motivation

Ausbildung

RN license (active in state)

Tools

CTI (Care Transitions Interv.)

Epic

Point Click Care (PPC)

Jobbeschreibung

Molina Healthcare is seeking a Care Transition Nurse/Coordinator to support members in Michigan’s Medicare and Integrated Duals programs, guiding them from hospital admission through post-acute settings to reduce readmissions.

Responsibilities include coordinating with discharge planners, hospital teams, and families; conducting in-person visits; educating members on medication management, follow-up care, and community resources; and applying the Coleman Care Transition model to ensure safe,