As a Transition of Care Coach, you will play a crucial role in supporting members during their transition from hospital admission to various other settings. Your primary goal will be to ensure that members receive the best possible services upon discharge, with a focus on reducing readmissions and promoting quality, cost-effective care. This hybrid position requires approximately 20% travel to hospital settings to support member needs. Your Impactful Responsibilities 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. Benefits Molina Healthcare offers a competitive benefits and compensation package. Why Join Our Team? Molina Healthcare offers a competitive benefits and compensation package. Who We Are Looking For We are seeking a proactive and detail-oriented Registered Nurse with a minimum of two years of case management experience, specifically working with pediatric and adolescent populations. You must reside in Florida and hold an active, unrestricted nursing license in the state. 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. A valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements are necessary, unless otherwise required by law. Demonstrated knowledge of community resources is required. You should be able to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. Responsive in all forms of communication, and able 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, critical-thinking, verbal and written communication skills are essential. Proficiency in Microsoft Office suite/other applicable software program(s) is also required. Join Our Team as a Transition of Care Coach (RN-Peds) in Miami, FL Are you a dedicated Registered Nurse with a passion for paediatric care and a desire to make a real difference? We're seeking a Transition of Care Coach to guide members through critical care transitions, ensuring seamless discharge and reduced readmissions. If you have experience in case management and love working with children, this hybrid role with travel offers a rewarding opportunity to impact lives.