Transition of Care Coach (RN)

Molina Healthcare•Long Beach, TX

3d•Onsite

About The Position

The Transition of Care Coach (RN) supports Texas Medicaid members recently admitted to a hospital. The coach partners with hospital discharge teams and supports members as they transition from inpatient care to a nursing facility or home. The role combines phone outreach with in-person meetings while members are hospitalized and includes local travel to designated hospitals. The position follows members through a 30-day program beginning at hospital admission and continuing through transitions to other settings, with the goal of reducing readmissions and supporting quality, cost-effective care. The coach coordinates care and reassesses needs after discharge using the Coleman Care Transition model. The role includes educating and motivating members on medication management, personal health records, follow-up care, signs and symptoms of worsening conditions, nutrition, functional needs and home- and community-based services, and advance directives. The position requires accurate documentation, strong computer skills, attention to detail, and the ability to manage multiple tasks in a fast-paced setting. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. CST, with no weekends, nights, holidays, or on-call work. Local travel may be 40–50%, depending on state or contractual requirements; mileage is reimbursed.

Requirements

At least 2 years of healthcare experience, 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; the role seeks a Texas-licensed RN.
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 approach.
Ability to work in varied settings and adapt to diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication methods and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, with ability to manage multiple projects and adapt to change.
Excellent problem-solving and critical-thinking skills.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office 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.
Previous case management, managed care, or inpatient hospital experience.
Experience in a behavioral health setting.

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 home, with the goal of reducing readmissions.
Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and members’ family or support networks to ensure safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving, functional support, and medical and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to ensure necessary services and equipment are in place for safe transitions.
Conduct face-to-face visits with members in the hospital and, as needed, post-discharge home visits for high-risk members.
Coordinate care and reassess member needs after discharge using the Coleman Care Transition model.
Educate and support members on medication management, personal health records, 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 members during 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 as appropriate to non-behavioral health care managers.
Conduct phone outreach and accurately document member contacts while managing multiple systems and tasks.
Travel locally to designated hospitals and, as required, other locations in the service delivery area.