RN Care Transition Navigator | Reduce Readmissions

Molina Healthcare Inc; Detroit (MI); On-site; USD 70,000 - 95,000; Full time

Job summary

Molina Healthcare is seeking an experienced Registered Nurse to lead care transition activities for Michigan health plan members across Medicare and Integrated Duals. This role emphasizes discharge planning, coordination with hospital staff, and interdisciplinary teams to reduce readmissions and ensure safe post-discharge care.

The RN will oversee 30-day transitions, collaborate with providers and family support networks, and educate members on medication management and follow-up needs.

Qualifications

• Minimum 2 years in health care with 1 year in discharge planning, care management or behavioral health.
• Must be a registered nurse with active license in state of practice.
• Valid driver's license and reliable transportation.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Experience with discharge planning or home health.
• Strong communication and problem-solving skills.

Responsibilities

• Follow member through a 30-day transition program from hospital admission through to post-discharge settings.
• Collaborate with discharge planners, hospitalists, outpatient providers, facility staff and family.
• Coordinate safe transitions with appropriate caregiving and medical oversight.
• Facilitate ICT meetings and provide education to care managers.
• Use Coleman Care Transition model to reassess member needs post-discharge.
• Educate members on medication management, follow-up care, warning signs, nutrition and home-based services.

Skills

RN

Care coordination

Discharge planning

Behavioral health

Time management

Communication skills

Microsoft Office

Tools

Epic

Point Click Care

Job description

Molina Healthcare is seeking an experienced Registered Nurse to lead care transition activities for Michigan health plan members across Medicare and Integrated Duals. This role emphasizes discharge planning, coordination with hospital staff, and interdisciplinary teams to reduce readmissions and ensure safe post-discharge care.

The RN will oversee 30-day transitions, collaborate with providers and family support networks, and educate members on medication management and follow-up needs.