Remote RN Transition of Care Coach (California License/PST Hours)

Molina Healthcare•United States,

3d•$24 - $51•Remote

About The Position

Provides support for care transition activities and facilitates transitional care processes and coordination for member discharge from hospital admission to other settings. The role strives to ensure that members have the best possible services available at hospital discharge, with a focus on reducing readmissions and contributing to quality, cost-effective member care. The position follows members through a 30-day program beginning at hospital admission and continuing through transitions to settings such as a nursing facility or private home. It involves collaboration with discharge planners, hospitalists, outpatient providers, facility staff, families and support networks, as well as arranging needed services and equipment. The coach conducts face-to-face hospital visits and, when needed, home visits for high-risk members after discharge. The role coordinates and reassesses care using the Coleman Care Transition model, educates and supports members across the seven Transition of Care Pillars, addresses barriers to care, and facilitates interdisciplinary collaboration. Local travel of 40–50% may be required, depending on state and contractual requirements.

Requirements

At least 2 years of experience in health care, including at least 1 year in hospital discharge planning, care management, or a behavioral health setting, or an equivalent combination of relevant education and experience.
Active, unrestricted Registered Nurse (RN) license in the state of practice.
Valid, unrestricted driver's license, reliable transportation, and adequate auto insurance for job-related travel, unless otherwise required by law.
Knowledge of or experience using the Care Transitions Intervention (CTI) or a similar model.
Background in discharge planning and/or home health.
Demonstrated knowledge of community resources.
Proactive and detail-oriented.
Ability to work in a variety of settings and adjust style when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsive across forms of communication and able to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills; ability to manage multiple projects simultaneously and adapt to change.
Excellent problem-solving and critical-thinking skills.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office suite and other applicable software programs.

Nice To Haves

Transitions of care subspecialty certification and/or Certified Case Manager (CCM).
Hospital discharge planning or home health experience.

Responsibilities

Follow members through a 30-day program beginning at hospital admission and oversee transitions from acute care to other settings, including nursing facility placement or a private home, with the goal of reducing readmissions.
Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family or support networks to ensure safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving and functional support, as well as medical and medication oversight.
Work with participating ancillary providers, public agencies, and other service providers to ensure necessary services and equipment are in place for a safe transition.
Conduct face-to-face visits with members in the hospital and home visits with high-risk members after discharge as needed.
Coordinate care and reassess member needs after discharge using the Coleman Care Transition model.
Educate and support members in medication management, use of a personal health record, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs and home- and community-based services, and advance directives.
Use motivational interviewing and Molina clinical guideposts to educate, support, and motivate change during member contacts.
Assess barriers to care and provide care coordination and assistance to address member concerns.
Facilitate interdisciplinary care team meetings and collaboration.
Provide consultation, recommendations, and education to non-behavioral health care managers as appropriate.
Travel locally as required; 40–50% travel may be required based on state and contractual requirements.