Transition of Care Coach (RN)

Molina Healthcare; San Antonio (TX); Remote; USD 10,000 - 60,000; Full time

Job summary

A leading healthcare provider is seeking a TX licensed RN for a fully remote position, focusing on supporting members transitioning from hospital to home. The ideal candidate will have experience in hospital discharge planning. Responsibilities include collaborating with healthcare teams, conducting patient visits, and ensuring safe transitions. Competitive hourly pay offered, with potential local travel required.

Benefits

Competitive benefits and compensation

Equal Opportunity Employer

Qualifications

• Graduate from an Accredited School of Nursing.
• 1-3 years hospital discharge planning or home health experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Ensure smooth transitions for members from hospital to home.
• Conduct face-to-face visits and follow-up care.
• Collaborate with hospital staff and outpatient providers.

Skills

Member support

Collaboration

Motivational interviewing

Medication management

Care coordination

Education

Bachelor's Degree in Nursing

Tools

Microsoft Office Suite

Job description

Overview

Opportunity for TX licensed RN to join our DSNIP team to work with our members who are hospitalized and ready to be discharged. The RN hired for this position will work with the hospital discharge team to ensure that all appropriate resources, doctor appointments, etc. are ready so that the transition out of the facility occurs smoothly. At this time, this position is fully remote, working from home, but there is a chance that, in the future, you may have to go into the field to complete assessments on those members on your caseload. Preference will be given to candidates with experience working as a Transition of Care Coach with another MCO like Molina. Additional pluses – experience with the LTSS or Behavioral Health populations. Bilingual is also a plus.

Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.

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.

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 required.

Job Qualifications

Required Education

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

Required Experience

1-3 years hospital discharge planning or home health.

Required License, Certification, Association

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Must have valid driver's license with 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 hospital discharge planning or home health.

Preferred License, Certification, Association

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

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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 - $51.49 / HOURLY

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