(RN)Transition of Care Coach (Massachusetts based)

Molina Healthcare • Boston, MA • 3h ago

JOB DESCRIPTION Job Summary

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.

Essential Job Duties

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).

Required Qualifications

At least 2 years 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 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.

Preferred Qualifications

Transitions of care sub-specialty certification and/or Certified Case Manager (CCM).

Hospital discharge planning or home health experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $30.37 - $59.21 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

Retail Sales Specialist

Staples • Chelmsford, MA • 19min ago

Retail & Hospitality

Sales Specialists provide exceptional customer service in helping our customers find a total solution both in-store and through the kiosk. You'll have our customers' needs in mind as you provide solutions. You will also...

19min ago

Go to Apply

Security Officer Retail

Allied Universal • Boston, MA • 20min ago

Retail & Hospitality

Company Overview: Allied Universal®, North America's leading security and facility services company, offers rewarding careers that provide you a sense of purpose. While working in a dynamic, welcoming, and collaborative...

20min ago

Go to Apply

Entry Level Architect (Data Centers)

Jacobs • Boston, MA • 23min ago

Management & Administrative

We are searching for an Entry Level Architect to join our Data Centers team in a hybrid capacity at any of our US based locations. In this position you'll contribute to projects that enable the heart of our clients' busi...

23min ago

Go to Apply

Account Manager - Private Client Group

HUB International • Wilmington, MA • 23min ago

Management & Administrative

Discover a Career That Empowers You - Join HUB International! At HUB International, we're more than just an insurance brokerage firm - we're a thriving community of entrepreneurs driven by purpose and passion. Every day,...

23min ago

Go to Apply

Retail Client Merchandising Representative

Acosta Group • Randolph, MA • 29min ago

Retail & Hospitality

Retail Client Merchandising Representative General Information Company: CRO-US Location: RANDOLPH, Massachusetts, 02368 Ref #: 134219 Pay Rate: $ 17.00 Experience/skills and/or location may influence position wage rate R...

29min ago

Go to Apply

Account Manager, Enterprise

allego • Boston, MA • 29min ago

Management & Administrative

About Allego Allego is a rapidly growing SaaS technology company headquartered in the metro Boston area, delivering a modern, AI-powered revenue enablement platform for today's distributed sales teams. Our platform combi...

29min ago

Go to Apply

Sr. District Sales Manager

ThermoFisher Scientific • Waltham, MA • 31min ago

Retail & Hospitality

Work Schedule Standard (Mon-Fri) Environmental Conditions Office Job Description As part of the Thermo Fisher Scientific team, you'll discover meaningful work that makes a positive impact on a global scale. Join our coll...

31min ago

Go to Apply