Transition of Care Coach (RN)

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

Job summary

Molina Healthcare seeks a Nurse for Care Transitions to support 30-day post-hospital programs, coordinating care across settings and reducing readmissions. You will partner with hospital teams, providers, and family to ensure seamless transitions and timely access to services.

The role requires an active RN license, 2+ years in healthcare with discharge planning experience, and willingness to travel 40–50% locally as needed. Strong communication and organization are essential.

Qualifications

• At least 2 years in health care with 1 year in discharge planning, care management or behavioral health setting.
• RN license active and unrestricted in state of practice.
• Valid driver license, transportation, and adequate auto insurance for travel.
• Knowledge of Care Transitions Intervention (CTI) or similar model.
• Background in discharge planning and/or home health.

Responsibilities

• Follows member through a 30-day program from hospital admission to post-discharge settings to reduce readmissions.
• Collaborates with hospital discharge planner, hospitalists, outpatient providers, facility staff and family.
• Ensures safe transitions with adequate caregiving and medical oversight.
• Coordinates with ancillary providers and public agencies to arrange necessary services.
• Conducts face-to-face visits in hospital and home visits for high-risk members post-discharge.
• Reassesses member needs using the Coleman Care Transition model post-discharge.

Skills

Care coordination

Discharge planning

Communication skills

Time management

Microsoft Office proficiency

Education

Registered Nurse (RN) license

Tools

Microsoft Office

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

Pay Range: $27.73 - $54.06 / HOURLY. *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.