RN Transition of Care Coach — Discharge & Care Coordination

Molina Healthcare; Illinois; Hybrid; USD 39,000 - 74,000; Full time

Job summary

Molina Healthcare is seeking a qualified RN to coordinate transitions of care, from hospital discharge through follow-up in various settings. You will work with hospital discharge planners, providers, and families to ensure safe, effective transitions and reduce readmissions.

Responsibilities include conducting post-discharge visits, applying CTI or similar models, and educating members on medication management and follow-up care. Travel may be required (40-50%) depending on state requirements.

Qualifications

• Requires RN license active and unrestricted.
• Minimum 2 years healthcare experience with discharge planning or care management.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Proactive and detail-oriented with strong communication skills.
• Proficient in Microsoft Office and related software.

Responsibilities

• Follows members through a 30-day transition program from hospital admission through to post-discharge settings.
• Collaborates with hospital discharge planners, hospitalists, outpatient providers, facility staff and families.
• Ensures safe transitions with adequate caregiving, medical oversight and medication management.
• Coordinates with ICT and interdisciplinary teams to plan and reassess member needs.
• Provides education and support to members across transition pillars and follow-up care.
• Maintains professional relationships and communicates effectively in high-pressure situations.

Skills

Care transitions

Discharge planning

Health care experience

Communication skills

Critical thinking

Time management

Independent work

Travel readiness

CTI knowledge

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a qualified RN to coordinate transitions of care, from hospital discharge through follow-up in various settings. You will work with hospital discharge planners, providers, and families to ensure safe, effective transitions and reduce readmissions.

Responsibilities include conducting post-discharge visits, applying CTI or similar models, and educating members on medication management and follow-up care. Travel may be required (40-50%) depending on state requirements.