As an RN- Transition of Care Coach, you will play a crucial role in supporting members through their care transitions. Your primary responsibilities will include facilitating discharge processes, coordinating care from hospital admission to various settings, and ensuring members receive the best possible services to reduce readmissions. This position is integral to providing quality and cost-effective care. Your Role as a Transition of Care Coach Follow members through a 30-day program from hospital admission to various settings, 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, public agencies, or other service providers to secure necessary services and equipment for safe transitions. Conduct face-to-face visits with members in the hospital and home visits for high-risk members post-discharge. 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, provide care coordination, and assist members in addressing concerns. Facilitate interdisciplinary care team meetings and collaboration. Provide consultation, recommendations, and education to non-behavioral health care managers as appropriate. What We Offer Competitive benefits package Competitive compensation package What We Offer Molina Healthcare offers a competitive benefits and compensation package to its employees, ensuring a supportive and rewarding work environment. Who Excels as an RN- Transition of Care Coach? We are seeking a highly skilled and compassionate RN- Transition of Care Coach who possesses a strong background in healthcare, particularly with experience in hospital discharge planning, care management, or behavioral health. The ideal candidate will hold an active and unrestricted Registered Nurse license and be proficient in using care transition models such as CTI. You should be proactive, detail-oriented, and capable of working independently while adapting your approach to diverse populations and situations. Excellent communication, time-management, and problem-solving skills are essential, as is the ability to maintain professional relationships and remain calm under pressure. A valid driver's license, reliable transportation, and adequate auto insurance are also required due to the travel demands of the role. Knowledge of community resources and proficiency in Microsoft Office suite are also important. At least 2 years of experience in healthcare, with 1 year in hospital discharge planning, care management, or behavioral health. Active and unrestricted Registered Nurse (RN) 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. Ability to work effectively in diverse settings and adapt style to various populations and situations. Ability to work independently with minimal supervision and demonstrate self-motivation. Responsive communication skills and ability to remain calm in high-pressure situations. Ability to develop and maintain professional relationships. Excellent time-management, prioritization, problem-solving, and critical-thinking skills. Proficiency in Microsoft Office suite and other applicable software programs. Why This Role? Opportunity to reduce member readmissions Work with diverse populations and personal situations Ability to work independently with minimal supervision Develop and maintain professional relationships Focus on multiple projects simultaneously Impactful Care Coordination for Members Join Molina Healthcare as an RN- Transition of Care Coach and play a crucial role in supporting members through critical care transitions. This position offers the chance to significantly impact patient outcomes by reducing readmissions and ensuring seamless care coordination, all while enjoying competitive compensation and a supportive environment.