Transition of Care Coach (RN) Remote with Field Travel in Seattle WA

Sauk Prairie Healthcare, Inc.; Kansas City (KS); Remote; USD 10,000 - 60,000; Full time

Job summary

A leading healthcare provider is seeking a Transition of Care Coach (RN) who will work with patients to coordinate care transitions effectively. This remote position requires collaboration with multidisciplinary teams and travel to hospital facilities in Seattle, WA. Candidates should possess a valid RN license and have experience in discharge planning, emphasizing patient education and care coordination in daily tasks. Join a dedicated team focused on quality care and patient outcomes.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• Bachelor's Degree in Nursing preferred.
• Graduate from an accredited School of Nursing.
• 1-3 years of experience in hospital discharge planning or home health.

Responsibilities

• Follow members throughout a 30-day program post-hospital admission to ensure safe transitions.
• Coordinate care and collaborate with medical staff and family networks.
• Conduct face-to-face visits for high-risk members post-discharge.

Skills

Care Coordination

Medication Management

Patient Education

Motivational Interviewing

Discharge Planning

Education

Bachelor's Degree in Nursing

Graduate from an accredited School of Nursing

Job description

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Transition of Care Coach (RN) Remote with Field Travel in Seattle WA - New

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.

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.

We are seeking a candidate with a WA state RN licensure. Candidates with case management and hospital-facility experience are highly preferred. Bilingual candidates are encouraged to apply. Further details will be discussed during our interview process.

Remote with field travel to hospital facilities in Seattle, WA - King County.

Work schedule: Monday - Friday: 8:00 am - 5:00 pm PST.

RN WA licensure required.

Knowledge/Skills/Abilities

• Follow members throughout a 30-day program starting at hospital admission and continuing through transitions from the acute setting to other settings, including nursing facilities and private homes, aiming to reduce readmissions.
• Ensure safe and appropriate transitions by collaborating with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family/support networks as needed.
• Ensure member transitions to a setting with adequate caregiving, functional support, and medical oversight.
• Coordinate with ancillary providers, public agencies, or other service providers to ensure necessary services and equipment are in place for a safe transition.
• Conduct face-to-face visits in the hospital and home visits for high-risk members post-discharge.
• Coordinate care and reassess needs using the Coleman Care Transitions Model.
• Educate and support members on medication management, use of personal health records, follow-up care, symptoms of worsening conditions, nutrition, functional needs, and advance directives.
• Use motivational interviewing and Molina clinical guideposts to educate, support, and motivate change.
• Assess barriers to care and provide care coordination and assistance.
• Facilitate interdisciplinary care team meetings and informal ICT collaboration.
• Provide consultation, recommendations, and education to non-RN case managers as needed.
• Manage cases with members who have complex medical conditions and medication regimens.
• Conduct medication reconciliation when needed.
• Approximately 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.
• Valid driver's license with a good driving record and 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: Please apply through the intranet job listing if interested.

Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V.

#PJHPO

Pay Range: $26.41 - $59.21 / HOURLY

• Actual compensation may vary based on location, experience, education, and skill level.