RN Transition of Care Coach: Discharge & Care Coordination

Molina Healthcare; Elgin (IL); On-site; USD 38,000 - 74,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support care transition activities, ensuring safe and cost-effective discharge planning and post-discharge follow-up across settings. You will coordinate with hospital teams, providers, and families to reduce readmissions and support members during a 30-day transition program.

Responsibilities include conducting visits, educating members on transition pillars, using CTI and motivational interviewing, and traveling locally up to 50% to ensure

Qualifications

• At least 2 years experience in health care with at least 1 year in hospital 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 travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Strong communication and time-management skills.

Responsibilities

• Follows member through a 30 day program starting at hospital admission and coordinates transitions to other settings to reduce readmissions.
• Collaborates with hospital discharge planner, hospitalists, outpatient providers, facility staff, and family to ensure safe transitions.
• Ensures appropriate caregiving, functional support, and medical oversight post-discharge.
• Coordinates with ancillary providers and public agencies to arrange needed services and equipment.
• Conducts face-to-face hospital visits and post-discharge home visits for high-risk members.
• Educates members on Transition of Care pillars and uses Coleman Care Transition model.
• Facilitates interdisciplinary care team meetings and provides education to care managers.

Skills

RN

Discharge planning

Care management

Communication

Time management

Driver's license

CTI knowledge

Problem solving

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Registered Nurse to support care transition activities, ensuring safe and cost-effective discharge planning and post-discharge follow-up across settings. You will coordinate with hospital teams, providers, and families to reduce readmissions and support members during a 30-day transition program.

Responsibilities include conducting visits, educating members on transition pillars, using CTI and motivational interviewing, and traveling locally up to 50% to ensure