RN Care Transitions Coach — Reduce Readmissions

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

Job summary

Molina Healthcare is seeking a skilled RN to provide care transition support and discharge planning, guiding members from hospital admission through transitions to home or other settings. You will coordinate with hospitals, providers, facilities, and families to reduce readmissions and ensure safe, effective care.

Responsibilities include conducting in-hospital and post-discharge visits, applying the Coleman Care Transition model, and educating members on key pillars of care.

Qualifications

• At least 2 years' experience in health care with at least 1 year in discharge planning, care management or behavioral health.
• 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.
• Proactive and detail-oriented; able to work with minimal supervision.
• Excellent verbal and written communication, time-management, and problem-solving skills.

Responsibilities

• Follow member through a 30-day program from hospital admission to transitions.
• Collaborate with discharge planner, hospitalists, providers, facility staff, and family.
• Ensure safe transitions with adequate caregiving and medical oversight.
• Coordinate with public agencies and other service providers for needed services.
• Conduct face-to-face hospital visits and post-discharge home visits for high-risk members.
• Reassess member needs using the Coleman Care Transition model post-discharge.
• Educate on seven Transition of Care Pillars: meds, records, follow-up, symptoms, nutrition, functional needs, home services.
• Participate in ICT meetings and provide education to non-behavioral health managers.
• Travel 40-50% locally as required by state/contractual obligations.

Skills

Health care experience

Hospital discharge planning

Care management

Behavioral health setting

Communication skills

Time management

Problem-solving

Critical thinking

Independent work

Driver's license

Microsoft Office

Education

Registered Nurse (RN) license

Tools

Care Transitions Intervention (CTI) knowledge

Microsoft Office

Job description

Molina Healthcare is seeking a skilled RN to provide care transition support and discharge planning, guiding members from hospital admission through transitions to home or other settings. You will coordinate with hospitals, providers, facilities, and families to reduce readmissions and ensure safe, effective care.

Responsibilities include conducting in-hospital and post-discharge visits, applying the Coleman Care Transition model, and educating members on key pillars of care.