RN Transition of Care Coach remote based in WA state

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

The RN Transition of Care Coach provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Washington State Medicare plan. We are seeking a candidate with a WA RN licensure and previous Case Management experience. The candidate should have proficient knowledge of MS Suite, organized and analytical thinking. Experience with care coordination and discharge planning highly preferred.. Further details to be discussed during our interview process. Remote position based in Washington State Work schedule Monday through Friday 8:30 AM to 5:00 PM PST. WA RN licensure required.

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 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 high-risk members post-discharge as needed. Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge. Educates and supports member 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 member to address concerns. Facilitates interdisciplinary care team meetings (ICT) and collaboration. Provides consultation, recommendations and education as appropriate to non-behavioral health care managers. 40-50% local travel may be required (based upon state/contractual requirements).