Transitions of Care Registered Nurse Coach

JOB DESCRIPTION\n\nJob Summary\n\nMolina Healthcare Services (HCS) is dedicated to providing exceptional care and support for members with high needs. Our mission is to collaborate with members, providers, and our multidisciplinary team to facilitate and coordinate an integrated delivery of care across various settings, including behavioral health and long-term care. Our team focuses on ensuring patients successfully progress toward their desired health outcomes, receiving care that is both effective and cost-efficient.\n\nKEY RESPONSIBILITIES\n

• Guide members through a comprehensive 30-day program that initiates upon hospital admission and continues throughout transitions to different care environments, such as nursing facilities or home settings, all aimed at minimizing readmissions.\n
• Work collaboratively with hospital discharge planners, hospitalists, outpatient providers, facility staff, and the member's support network to ensure safe and appropriate transitions.\n
• Verify that members move to environments with sufficient caregiving and functional support, along with necessary medical and medication oversight.\n
• Coordinate with ancillary providers and service agencies to arrange essential services and equipment for secure transitions.\n
• Conduct face-to-face visits at hospitals and post-discharge home visits for high-risk members.\n
• Reassess member needs and coordinate care using the Coleman Care Transitions Model during the critical post-discharge period.\n
• Educate and empower members across key areas such as medication management, personal health records, follow-up care, identifying signs of worsening conditions, nutrition, functional needs, Home and Community-based Services, and advance directives.\n
• Utilize motivational interviewing techniques and Molina's clinical guidelines to support members and inspire positive changes.\n
• Identify barriers to care and provide necessary coordination and assistance to address member concerns.\n
• Facilitate interdisciplinary care team meetings and collaboration among team members.\n
• Provide consultation, recommendations, and educational support to non-RN case managers as needed.\n
• Handle complex cases involving members with intricate medical conditions and medication regimens.\n
• Perform medication reconciliation when necessary.\n\nQUALIFICATIONS\n\nRequired Education\n\nGraduate from an Accredited School of Nursing; a Bachelor's Degree in Nursing is preferred.\n\nRequired Experience\n\n1-3 years in hospital discharge planning or home health care settings.\n\nRequired License and Certification\n
• Valid, unrestricted State Registered Nursing (RN) license in good standing.\n
• Must have a valid driver's license, a clean driving record, and reliable transportation.\n\nNote : California applicants must hold a license specific to California, as it is not a compact state.\n\nPreferred Qualifications\n\nPreferred Education\n\nBachelor's Degree in Nursing.\n\nPreferred Experience\n\n3-5 years in hospital discharge planning or home health settings.\n\nPreferred License and Certification\n\nActive, unrestricted Transitions of Care Sub-Specialty Certification and / or Certified Case Manager (CCM).\n\nWork Schedule : Monday to Friday during Pacific Business Hours.\n\nRemote Position : Candidates may reside anywhere in the USA but must work Pacific hours. California or West Coast USA residents are preferred. No travel is required for this role.\n\nJoin Molina Healthcare, a company committed to equal opportunity in employment. We offer a competitive benefits and compensation package.\n\nPay Range : $30.37 - $51.49 / HOURLY. Actual compensation may vary based on geographic location, experience, education, and skills.