RN - Care Transition & Discharge Coordinator

Molina Talent Acquisition; Fitchburg (MA); On-site; USD 70,000 - 100,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support care transitions and discharge planning, ensuring safe, coordinated steps from hospital to home or facility. The role emphasizes preventing readmissions and coordinating with hospital teams, families, and community resources.

The candidate will conduct hospital and post-discharge visits, collaborate with ICTs, and use standard care transition models to guide patient care, with substantial travel as required by state contracts.

Qualifications

• Active RN license in state of practice.
• Experience in discharge planning or care transitions essential.
• Familiarity with Care Transitions Intervention (CTI) model preferred.

Responsibilities

• Support care transition activities from hospital to home or other settings.
• Coordinate with discharge planners, hospitalists, and providers to ensure safe transitions.
• Monitor patient needs post-discharge and adjust plan accordingly.
• Facilitate interdisciplinary care team meetings and document care plans.
• Conduct face-to-face visits during hospital stay and post-discharge visits as needed.
• Travel 40-50% based on state/contractual requirements.

Skills

RN license

Discharge planning

Care transitions

Driver's license

CTI knowledge

Communication skills

Time management

Travel required

Microsoft Office

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Registered Nurse to support care transitions and discharge planning, ensuring safe, coordinated steps from hospital to home or facility. The role emphasizes preventing readmissions and coordinating with hospital teams, families, and community resources.

The candidate will conduct hospital and post-discharge visits, collaborate with ICTs, and use standard care transition models to guide patient care, with substantial travel as required by state contracts.