As a Transition of Care Coach (RN), you will play a crucial role in supporting care transition activities and facilitating seamless coordination for member discharge from hospital admission to various other settings. Your primary goal will be to reduce member readmissions by ensuring the best possible services are available at the time of hospital discharge, contributing to the overarching strategy of providing quality and cost-effective member care. What You'll Do as a Transition of Care Coach Follow members through a 30-day program from hospital admission to discharge, aiming to reduce readmissions. Ensure safe transitions by collaborating with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family/support networks. Verify members transition to settings with adequate caregiving, functional support, and medical/medication oversight. Work with ancillary providers and public agencies to ensure necessary services and equipment are in place for safe transitions. Conduct face-to-face visits with members in the hospital and home visits for high-risk members post-discharge as needed. Coordinate care and reassess member needs using the Coleman Care Transition model post-discharge. Educate and support members on medication management, personal health records, follow-up care, worsening condition signs, nutrition, functional needs, home/community-based services, and advance directives. Utilise motivational interviewing and Molina clinical guideposts to educate, support, and motivate change during member contacts. Assess for barriers to care and provide coordination and assistance to address member concerns. Facilitate interdisciplinary care team meetings and collaboration. Provide consultation, recommendations, and education to non-behavioral health care managers. What We Offer You Competitive benefits package Competitive compensation package What We Offer You Molina Healthcare offers a competitive benefits and compensation package to its employees, ensuring a supportive and rewarding work environment for the Transition of Care Coach (RN). Who We're Looking For We are seeking a dedicated and experienced Registered Nurse to join our team as a Transition of Care Coach. The ideal candidate will possess at least two years of healthcare experience, including a minimum of one year in hospital discharge planning, care management, or a behavioural health setting. You must hold an active and unrestricted RN license in the state of practice and have a valid driver's license with reliable transportation for travel. 40-50% local travel may be required (based upon state/contractual requirements). A strong understanding of care transition models like CTI, coupled with a background in discharge planning or home health, is essential. We are looking for a proactive, detail-oriented individual who can work independently, adapt to diverse situations, and maintain professional relationships. Excellent communication, time-management, and problem-solving skills are crucial for success in this role. At least 2 years of experience in healthcare, with a minimum of 1 year in hospital discharge planning, care management, or behavioural health, or an equivalent combination of education and experience. Registered Nurse (RN) with an active and unrestricted license in the state of practice. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job-related travel. Knowledge of or experience using the Care Transitions Intervention (CTI) or a similar model. Background in discharge planning and/or home health. Demonstrated knowledge of community resources. Proactive and detail-oriented approach to work. Ability to work effectively in diverse settings and adapt communication styles. Ability to work independently with minimal supervision and demonstrate self-motivation. 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, prioritisation, problem-solving, and critical-thinking skills. Proficiency in Microsoft Office suite and other applicable software programs. Why Join Our Team? Purpose-driven culture focused on helping underserved communities Strong sense of meaning and purpose in your work Collaborative and supportive team relationships Values integrity and absolute accountability Values honest and open communication Member and community-focused approach Make a Difference as a Transition of Care Coach As a Transition of Care Coach (RN), you will play a crucial role in ensuring safe and appropriate transitions for members, aiming to reduce readmissions and improve health outcomes. This full-time position offers competitive hourly pay and the chance to make a significant impact on the lives of individuals through dedicated care coordination and support.