RN- Transition of Care Coach (Fitchburg, MA)

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

JOB DESCRIPTION Job Summary

Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support.
• Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition.
• Conducts face-to-face visits of all members while in the hospital and, home visits high-risk members post-discharge as needed.
• Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge.
• Educates and supports member focusing on seven primary areas (Transition of Care 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 (ICT) and collaboration.
• Provides consultation, recommendations and education as appropriate to non-behavioral health care managers.
• 40-50% local travel may be required (based upon state/contractual requirements).

Required Qualifications

• At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law.
• Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/other applicable software program(s) proficiency.

Preferred Qualifications

• Transitions of care sub-specialty certification and/or Certified Case Manager (CCM).
• Hospital discharge planning or home health experience.

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