Remote Care Transition Coach — Reduce Readmissions

Molina Healthcare; Las Vegas (NV); Remote; USD 34,000 - 68,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a Care Transition Specialist to support transition activities and coordinate discharge planning for members moving from hospital to home or other settings. This role primarily operates from home, focusing on reducing readmissions and aligning with overall quality of care.

The role covers a 30-day program, collaboration with hospital staff, providers, and families, and uses CTI-based guidelines to ensure safe, efficient transitions with strong communication and

Qualifications

• At least 2 years experience in health care, with at least 1 year in hospital discharge planning, care management or behavioral health.
• Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with active license if required.
• Valid driver's license, reliable transportation and auto insurance for travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Experience in discharge planning or home health.
• Excellent communication, time-management, and problem-solving skills.
• Proactive, detail-oriented, and able to work independently.

Responsibilities

• Follows member through a 30-day program from hospital admission to transitions.
• Collaborates with discharge planners, hospitalists, providers, and family.
• Ensures safe transitions with adequate caregiving and medical oversight.
• Coordinates with ancillary providers and community resources for services.
• Conducts face-to-face visits in hospital and home visits for high-risk members.
• Reassesses needs after discharge using Coleman Care Transition model.
• Educates members on medication management, follow-up care, and resources.
• Uses CTI guidelines to motivate change and address barriers.
• Facilitates interdisciplinary care team meetings as needed.

Skills

Time management

Prioritization

Communication

Problem solving

Critical thinking

Self-motivation

Independence

Education

LVN/LPN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Care Transition Specialist to support transition activities and coordinate discharge planning for members moving from hospital to home or other settings. This role primarily operates from home, focusing on reducing readmissions and aligning with overall quality of care.

The role covers a 30-day program, collaboration with hospital staff, providers, and families, and uses CTI-based guidelines to ensure safe, efficient transitions with strong communication and