RN Transition of Care Coach: Reduce Readmissions

Molina Healthcare; Detroit (MI); On-site; USD 70,000 - 90,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support transition-of-care activities for Michigan members across Medicare and Integrated Duals. The role focuses on reducing readmissions through coordinated discharge planning and post-discharge oversight.

Responsibilities include hospital-to-home transitions, collaboration with care teams, and member education on follow-up care and community services, with emphasis on safe, effective care delivery.

Qualifications

• RN license active and unrestricted in state of practice.
• 2+ years in health care with discharge planning or care management.
• Knowledge of CTI or similar transition models is a plus.
• Experience with hospital discharge planning or home health is preferred.
• Strong communication and organizational skills.

Responsibilities

• Support care transitions and 30-day post-discharge oversight.
• Collaborate with discharge planners, hospitalists, providers and family.
• Coordinate safe transitions to appropriate settings with supports.
• Conduct face-to-face hospital visits and home visits for high-risk members.
• Educate on medication management, follow-up care and access to services.
• Participate in ICT meetings and provide guidance to care managers.

Skills

RN license

Discharge planning

Care coordination

Communication skills

Time management

Problem solving

Microsoft Office

Education

Registered Nurse (RN) license

Tools

Epic

PointClickCare (PPC)

Microsoft Office Suite

Job description

Molina Healthcare is seeking a Registered Nurse to support transition-of-care activities for Michigan members across Medicare and Integrated Duals. The role focuses on reducing readmissions through coordinated discharge planning and post-discharge oversight.

Responsibilities include hospital-to-home transitions, collaboration with care teams, and member education on follow-up care and community services, with emphasis on safe, effective care delivery.