Transition of Care Coach (RN)

required

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.

To all current Molina

employees : If you are interested in applying for this position,

please apply through the Internal Job

Board.

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.