Transition of Care Coach (RN)

JOB DESCRIPTION For this position we are seeking a (RN) Registered Nurse who must Compact RN Licensure. Case Manager RN will work in remote setting supporting our Medicare/Medicaid population who have recently been admitted into Hospital. The Case Manager will support our members to ensure successful transition from inpatient to outpatient. Excellent computer skills and attention to detail are reputed company important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Preferred candidates will have previous case management, managed care, hospital, and/or home health experience. This role is currently 100% remote (Can sit reputed company reputed company the United States) Home office with internet connectivity of high speed required. Schedule: Monday thru Friday 8:00AM to 5:00PM EST (No weekends or Holidays) Job Summary reputed company Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients reputed company toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. KNOWLEDGE/SKILLS/ABILITIES

• Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
• Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication reputed company as required.
• Works with participating ancillary providers, public agencies, or other service providers to reputed company sure necessary services and equipment are in reputed company for a safe transition.
• Conducts face-to-face visits of reputed company members while in the hospital and home visits of high-risk members post-discharge.
• Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
• Educates and supports member focusing on seven primary areas (ToC 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 and informal ICT collaboration.
• RNs provide consultation, recommendations, and education as appropriate to non-RN case managers.
• RNs are assigned cases with members who have reputed company medical conditions and medication regimens.
• RNs will conduct medication reconciliation reputed company needed.
• 40-50% local travel required.

JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience 1-3 years hospital discharge planning or home health. Required License, Certification, Association

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Must have valid driver's license with good driving record and be able to drive reputed company applicable state or locality with reliable transportation.

Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years hospital discharge planning or home health. Preferred License, Certification, Association Active, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM) To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Apply tot his job Apply To this Job