RN Transition of Care Coach: Discharge Navigator

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

Job summary

Molina Healthcare in Rockford, IL seeks a Nurse Care Transition Specialist to support 30-day transition programs from hospital admission through discharge to home or facility. You will collaborate with discharge planners, hospitalists, and families to ensure safe, timely, and cost-effective care that reduces readmissions.

The ideal candidate is an RN with 2+ years in health care, CTI or similar model experience, and strong communication.

Qualifications

• At least 2 years in health care with at least 1 year in hospital discharge planning, care management or behavioral health setting.
• Active RN license in state of practice.
• Valid driver's license and reliable transportation for job-related travel.
• Experience using Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Ability to work independently and manage multiple tasks.

Responsibilities

• Follow member through a 30-day program from hospital admission through transitions to post-discharge settings to reduce readmissions.
• Collaborate with discharge planners, hospitalists, providers, facility staff, and family/support network.
• Ensure safe transitions with adequate caregiving and medical oversight.
• Coordinate with ancillary providers and public agencies to secure services/equipment.
• Conduct face-to-face hospital and home visits for high-risk members.
• Reassess needs using the Coleman Care Transition model post-discharge.
• Educate members on medication management, follow-up care, and self-care pillars.
• Use motivational interviewing and Molina guidelines to support behavior change.
• Identify barriers to care and provide coordination to address concerns.
• Facilitate ICT meetings and interdisciplinary collaboration.
• Provide guidance to non-behavioral health managers.
• Travel 40-50% as required.

Skills

Care coordination

Communication

Time management

Problem solving

Independence

Travel flexibility

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in Rockford, IL seeks a Nurse Care Transition Specialist to support 30-day transition programs from hospital admission through discharge to home or facility. You will collaborate with discharge planners, hospitalists, and families to ensure safe, timely, and cost-effective care that reduces readmissions.

The ideal candidate is an RN with 2+ years in health care, CTI or similar model experience, and strong communication.