(RN)Transition of Care Coach - (NM Based)

IntelliResume; Kansas; Hybrid; USD 36,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, a leading healthcare provider, seeks a Transition of Care Coach to support care transitions from hospital to home or other settings. The role focuses on proactive coordination to reduce readmissions and ensure seamless care for members.

The position is remote with full-time hours in the United States, requiring an active RN license, 2+ years in healthcare with discharge planning experience, and a valid driver's license.

Qualifications

• RN license active and unrestricted in the state of practice.
• Minimum 2 years experience in health care, with at least 1 year in discharge planning, care management, or behavioral health.

Responsibilities

• Follow members through a 30-day program from admission to transitions.
• Collaborate with discharge planners, hospitalists, outpatient providers, and families.
• Ensure transitions to settings with adequate caregiving and functional support.
• Coordinate care with ancillary providers and public agencies to arrange services.
• Conduct face-to-face hospital visits and home visits for high-risk members post-discharge.
• Coordinate care and reassess needs using the Coleman Care Transition model.
• Educate members on medication management and follow-up care.
• Use motivational interviewing to support change during contacts.
• Assess barriers to care and coordinate solutions.
• Facilitate interdisciplinary care team meetings.

Skills

Care coordination

Discharge planning

Motivational interviewing

Communication skills

Education

Registered Nurse (RN) license

Tools

Care Transitions Intervention (CTI)

Job description

About This Role

The Transition of Care Coach provides support for care transition activities, facilitating coordination for member discharge from hospital to other settings. This role is ideal for individuals who are proactive and detail-oriented, focusing on reducing member readmissions.

Highlights

• Pay: $26.41 - $51.49/hour
• Location: Remote, NM
• Schedule: Full Time

What You'll Do

• Follow members throughout a 30-day program from hospital admission to transitions to other settings.
• Collaborate with hospital discharge planners, hospitalists, outpatient providers, and family/support networks.
• Ensure transitions to settings with adequate caregiving and functional support.
• Work with ancillary providers and public agencies to ensure necessary services are in place.
• Conduct face-to-face visits with members in the hospital and home visits for high-risk members post-discharge.
• Coordinate care and reassess member needs using the Coleman Care Transition model post-discharge.
• Educate and support members on medication management, follow-up care, and other key areas.
• Use motivational interviewing to educate and motivate change during member contacts.
• Assess barriers to care and provide coordination and assistance to address concerns.
• Facilitate interdisciplinary care team meetings and collaboration.

Requirements

• Education:
  • Registered Nurse (RN) License must be active and unrestricted in state of practice.
• Experience:
  • At least 2 years experience in health care, with at least 1 year in hospital discharge planning, care management, or behavioral health.
• Licenses & Certifications:
  • Valid and unrestricted driver's license.
  • Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model.

Benefits

• Competitive benefits and compensation package.

About Molina Healthcare

Molina Healthcare is a leading healthcare provider committed to delivering exceptional patient care. They focus on providing quality and cost-effective services to their members.