Transition of Care Coach (RN)

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.

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 - $61.79 / HOURLY

• Actual compensation may vary

from posting based on geographic location, work experience,

education and / or skill level.