Transition of Care Coach (RN)

Molina Healthcare•Long Beach, CA

3d•Onsite

About The Position

The Transition of Care Coach (TOCC) is a Texas-licensed Registered Nurse who supports Texas Medicaid members recently admitted to a hospital. The coach partners with hospital discharge teams and supports members through their transition from inpatient care to a nursing facility or home. The work combines phone outreach with in-person meetings with members while they are still hospitalized. The role requires accurate documentation and multitasking across systems in a fast-paced, productivity-focused environment. The TOCC supports care transitions and coordinates discharge from hospital admission to other settings, aiming to ensure appropriate services are available at discharge, reduce readmissions, and contribute to quality, cost-effective care. The coach follows members through a 30-day program beginning at hospital admission, coordinates with clinical and community partners, and reassesses member needs after discharge using the Coleman Care Transition model. The position requires 40–50% local travel, including hospital visits and, when needed, post-discharge home visits for high-risk members. 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 duties.

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 position 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 adjust style when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication channels 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 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.
Excellent computer skills and attention to detail for multitasking across systems and entering accurate contact notes.

Nice To Haves

Transitions of care sub-specialty 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 a nursing facility, private home, or other setting, 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 ensure necessary services and equipment are in place for a safe transition.
Conduct face-to-face visits with members in the hospital and, as needed, home visits for high-risk members after discharge.
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.
Travel locally to designated hospitals and, as needed, members’ homes; local travel may be 40–50% based on state or contractual requirements.
Maintain accurate contact notes while communicating with members and working across computer systems.