Transition of Care Coach (RN)

Molina Healthcare•Long Beach, TX

About The Position

Molina Healthcare is seeking two Texas-licensed Registered Nurses to support Texas Medicaid members recently admitted to a hospital. One opening must be filled in El Paso; the other is open to Texas residents. The Transition of Care Coach (TOCC) 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. It requires strong computer skills, attention to detail, and the ability to multitask in a fast-paced, productivity-focused environment. Field travel to designated local hospitals is required; mileage is reimbursed. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. CST, with no weekends, nights, holidays, or on-call duty. The role provides support for care-transition activities and coordinates discharge from hospital admission to other settings. The coach aims to ensure appropriate services are available at discharge, reduce readmissions, and contribute to quality, cost-effective member care. Members are followed through a 30-day program beginning at hospital admission and continuing through transitions to other settings. The coach conducts hospital visits for all members and may conduct post-discharge home visits for high-risk members as needed. Local travel may be 40–50%, depending on state or contractual requirements.

Requirements

Registered Nurse (RN) with an active, unrestricted license in the state of practice; the openings require Texas licensure.
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.
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 a variety of settings and adapt communication and work style 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, ability to manage multiple projects simultaneously, and adaptability 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).
Previous case management, managed care, or inpatient hospital experience.
Experience in a behavioral health setting.
Hospital discharge planning or home health experience.

Responsibilities

Follow members throughout a 30-day program beginning at hospital admission and oversee transitions to nursing facilities, private homes, and other settings, with the goal of reducing readmissions.
Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and members’ families or support networks to ensure safe and appropriate transitions.
Ensure members transition to settings with adequate caregiving, functional support, medical oversight, and medication oversight.
Coordinate with ancillary providers, public agencies, and other service providers to arrange necessary services and equipment for safe transitions.
Conduct face-to-face visits with all members while they are 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 on 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 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 to non-behavioral health care managers as appropriate.
Conduct field travel to designated local hospitals and, as required, other local visits.