As a Transition of Care Coach, you will play a crucial role in supporting care transition activities for pediatric and adolescent members. You will facilitate transitional care processes from hospital admission to various settings, ensuring optimal services are available at discharge and working to reduce readmissions. This hybrid role involves some travel to hospital settings to directly support member needs. Your Impactful Responsibilities Follow members throughout a 30-day program, from hospital admission through transitions to other settings, to reduce readmissions Ensure safe and appropriate transitions by collaborating with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family/support networks Confirm members transition to settings with adequate caregiving, functional, medical, and medication oversight support Work with ancillary providers, public agencies, or other service providers to arrange necessary services and equipment for safe transition Conduct face-to-face hospital visits and post-discharge home visits for high-risk members as needed Coordinate care and reassess member needs using the Coleman Care Transition model post-discharge Educate and support members focusing on medication management, use of personal health records, follow-up care, signs of worsening condition, nutrition, functional needs, and advance directives Use motivational interviewing and 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 (ICT) and collaboration Provide consultation, recommendations, and education to non-behavioral health care managers Benefits Competitive compensation and benefits package Opportunity to contribute to quality and cost-effective member care Meaningful work impacting pediatric and adolescent health outcomes Your Well-being and Rewards Molina Healthcare values its employees and offers a competitive benefits and compensation package designed to support your overall well-being. This includes a robust compensation structure that reflects your experience and contributions to the team. Working with Molina Healthcare means being part of an organization committed to providing quality and cost-effective member care. Your role directly contributes to improving health outcomes for pediatric and adolescent populations, offering a sense of purpose and significant professional impact. Who We're Seeking We are looking for a Registered Nurse (RN) with an active and unrestricted nursing license in Florida, bringing at least two years of case management experience, specifically with pediatric and adolescent populations. The ideal candidate will possess a strong background in hospital discharge planning or home health, coupled with a proactive and detail-oriented approach. You should be able to work independently, demonstrate excellent time-management, problem-solving, and critical-thinking skills, and adapt your communication style to diverse situations. Knowledge of community resources and proficiency in Microsoft Office suite are also essential. Active, unrestricted Registered Nurse (RN) license in Florida Minimum 2 years of case management experience with pediatric and adolescent populations Valid and unrestricted driver's license with reliable transportation and adequate auto insurance Experience in hospital discharge planning or home health Knowledge of community resources Proactive and detail-oriented approach Ability to work independently with minimal supervision Excellent time-management and prioritization skills Strong problem-solving and critical-thinking abilities Excellent verbal and written communication skills Proficiency in Microsoft Office suite or other applicable software Beyond the Day-to-Day Hybrid work model with approximately 20% travel to hospital settings Opportunity to follow members throughout a 30-day program, ensuring continuous oversight Utilise motivational interviewing techniques to support member change Facilitate interdisciplinary care team meetings and collaboration Join Us as a Transition of Care Coach (RN-Peds) - Make a Real Difference! Are you a dedicated Registered Nurse with paediatric case management experience looking to make a significant impact on patient care? Join Molina Healthcare in Miami, FL, and play a crucial role in ensuring seamless transitions for our members from hospital to home, reducing readmissions and improving health outcomes. This hybrid role offers a chance to utilise your expertise in a supportive and engaging environment.