(RN)Transition of Care Coach (Massachusetts based)

Molina Healthcare • Springfield, 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 Associate

Staples • Enfield, CT • 13min ago

Retail & Hospitality

Sales Associates provide exceptional customer service with our customers' needs in mind. You'll help customers find products, provide solutions, and handle returns or online pickups. You'll also be collaborative and incl...

13min ago

Go to Apply

Retail Sales Associate (In-Store Sales)

AAA Mid Atlantic • Manchester, CT • 15min ago

Retail & Hospitality

Join Us Today! Unlock Your Sales Potential at AAA Club Alliance! Are you passionate about delivering exceptional service while driving sales success? Join our team and be part of a dynamic retail environment where every...

15min ago

Go to Apply

Retail Print Sales Specialist

Staples • Enfield, CT • 19min ago

Retail & Hospitality

Print Specialists provide exceptional customer service and solutions to customers' print needs. You will produce professionally finished products using print and production equipment. You will also be collaborative and i...

19min ago

Go to Apply

Housing Program Assistant

The Salvation Army • Hartford, CT • 34min ago

Overview Location: Marshall House Shelter (Hartford, CT) Status: Exempt, Full-time Hours Per Week: 40 minimally (on-call responsibility for two weeks of every four weeks, weekend hours as needed) Schedule: Monday-Friday,...

34min ago

Go to Apply

Contract Administrator

Hartford HealthCare • Hartford, CT • 4h ago

Work whereevery momentmatters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Con...

4h ago

Go to Apply

Aircraft Maintenance Crew Chief

RTX Corporation • East Granby, CT • 4h ago

Retail & Hospitality

Date Posted: 2026-05-06 Country: United States of America Location: US-CT-EAST GRANBY-200 ~ 200 Signature Way ~ OFFICE Position Role Type: Onsite U.S. Citizen, U.S. Person, or Immigration Status Requirements: Must be aut...

4h ago

Go to Apply

Configuration Management Specialist

Serco • Hartford, CT • 5h ago

Management & Administrative

Position Description & Qualifications The Army PPB BOS program is seeking a CM Specialist to deliver cloud-based configuration management, DevSecOps, and release engineering activities to support the enterprise syste...

5h ago

Go to Apply

Medical Secretary

Trinity Health • Hartford, CT • 5h ago

Hospital & Medical

Employment Type: Full time Shift: Day Shift Description: Trinity Health Of New England Medical Group is looking for a Medical Secretary to join our GYN Oncology team. The Medical Secretary functions in a supportive role...

5h ago

Go to Apply

Fujifilm Sales Manager- Print/Graphics Industry

Fujifilm • Hartford, CT • 5h ago

Management & Administrative

Position Overview Responsible for working within an assigned territory or market segment, to increase total territory sales through new account acquisition, and new product penetration in existing Fujifilm customers. Sel...

5h ago

Go to Apply

Administrative Assistant

Robert Half • Amherst, MA • 6h ago

Management & Administrative

Description Our client in Amherst, Massachusetts is seeking a dependable and organized Administrative Assistant for a contract opportunity. This role is ideal for someone who thrives in a fast-paced office environment an...

6h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)