Transition of Care Coach (RN) (Pacific Business hours)

Molina Healthcare; Miami (FL); Remote; USD 100,000 - 125,000; Full time

Job summary

A healthcare company is seeking an experienced RN for care coordination roles, focusing on transitional care for patients. Responsibilities include assessing member needs and facilitating safe transitions from hospital to home. Candidates must have a nursing license and experience in discharge planning. The position is remote but requires working Pacific hours, with a competitive pay range.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• 1-3 years hospital discharge planning or home health experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Experience conducting face-to-face visits and considering a member's overall health.

Responsibilities

• Coordinate with healthcare providers for safe patient transitions.
• Educate members on health management and support needs.
• Conduct assessments and care planning for high-risk members.

Skills

Member coordination

Care transition planning

Motivational interviewing

Medication management

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

JOB DESCRIPTION

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.

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)

Work Schedule

Work schedule :M - F Pacific Business Hours

Candidates can live anywhere in the USA but must work PACIFIC hours.

California or West Coast USA Residents preferred

Remote, no travel required.

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 - $61.79 / HOURLY

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