Transition of Care Coach (RN) - Must live in IL

Molina Healthcare•Long Beach, CA

1d•Remote

About The Position

This is a remote field-based opportunity requiring travel in Lake, Cook, DuPage, McHenry, Kane, and Jackson counties. The Transition of Care Coach (RN) provides support for care transition activities. They facilitate transitional care processes and coordination for member discharge from hospital admission to all other settings. The role strives to ensure that best possible services are available to members at the time of hospital discharge, with the goal of reducing member readmissions. This position contributes to the overarching strategy to provide quality and cost-effective member care.

Requirements

At least 2 years of 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 the 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.

Nice To Haves

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

Responsibilities

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 a 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 for high-risk members post-discharge as needed.
Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge.
Educates and supports members 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 members to address concerns.
Facilitates interdisciplinary care team meetings (ICT) and collaboration.
Provides consultation, recommendations, and education as appropriate to non-behavioral health care managers.