RN Transition of Care Coach field travel in Pierce or Snohomish WA

Molina Healthcare; Everett (WA); Remote; USD 10,000 - 60,000; Full time

Job summary

A healthcare provider is seeking an experienced RN for a position focused on case management and transitions of care. The role includes facilitating safe transitions from hospital to home, conducting both in-facility and home visits, and collaborating with interdisciplinary teams. Candidates must possess a valid Washington RN license and have experience in hospital discharge planning. This position offers a flexible remote work arrangement with required travel in Pierce or Snohomish County.

Benefits

Competitive benefits package

Equal Opportunity Employer

Flexible work hours

Qualifications

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• 1-3 years of hospital discharge planning or home health experience.
• Valid driver's license with a good driving record.

Responsibilities

• Facilitates safe transitions for members from hospital to home.
• Collaborates with hospital discharge planners and family networks.
• Conducts face-to-face and home visits for high-risk members.
• Coordinates care and reassesses member's needs post-discharge.

Skills

Case management

Hospital discharge planning

Bilingual communication

Motivational interviewing

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

JOBSITE DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

We are seeking a candidate with a WA state RN licensure. Candidates with case management and hospital- facility experience are highly preferred. Bilingual candidates are encouraged to apply. Further details will be discussed during our interview process.

Remote with field travel to hospital facilities in Pierce or Snohomish County.

Work schedule: Monday - Friday, 8:00am - 5:00pm PST.

RN WA licensure is required

KNOWLEDGE/SKILLS/ABILITIES

• Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
• Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required.
• Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.
• Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members post-discharge.
• Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
• Educates and supports member focusing on seven primary areas (ToC Pillars): medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and/or Home and Community-based Services, and advance directives.
• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.
• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.
• Facilitates interdisciplinary care team meetings and informal ICT collaboration.
• RNs provide consultation, recommendations, and education as appropriate to non-RN case managers.
• RNs are assigned cases with members who have complex medical conditions and medication regimens.
• RNs will conduct medication reconciliation when needed.
• 40-50% local travel is required.

JOB QUALIFICATIONS

Required Education

Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing is preferred.

Required Experience

1-3 years of hospital discharge planning or home health experience.

Required License, Certification, Association

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Must have a valid driver's license with a good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Education

Bachelor's Degree in Nursing

Preferred Experience

3-5 years of hospital discharge planning or home health experience.

Preferred License, Certification, Association

Active, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM)

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 - $59.21 per hour

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.