Transition of Care Coach (RN): California
Molina Healthcare San Jose, California; Los Angeles, California; Sacramento, California; San Francisco, California; San Diego, California Job ID 2031924**California residency required
JOB DESCRIPTION
Job Summary
Molina Healthcare 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 progress 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 oversight as required.
- Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.
- Conducts face-to-face visits of all 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 complex medical conditions and medication regimens.
- RNs will conduct medication reconciliation when needed.
- Very seldom local travel will be 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
- Current California 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 within 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 all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $30.37 - $59.21 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 06/17/2025ABOUT OUR LOCATION
View Map- Field Family Nurse Practitioner (Walnut Creek, CA) Walnut Creek California, Clayton California, Alamo California, Pleasant Hill California, San Ramon California, Concord California 07/01/2025
- UM LVN Delegation Oversight Nurse Remote based in CA (CA License) Los Angeles California, San Francisco California, Oakland California, San Diego California, San Jose California 07/07/2025
- Manager, Medical Economics (Pop Health/Clinical Analytics) - REMOTE Albany New York, Everett Washington, Florida, Kentucky, Nebraska, Iowa, Georgia, Michigan, Texas, Utah, Idaho, New York, Ohio, Washington, Rio Rancho New Mexico, Salt Lake City Utah, Ann Arbor Michigan, Grand Rapids Michigan, Miami Florida, Syracuse New York, Yonkers New York, Covington Kentucky, Des Moines Iowa, Columbus Ohio, Layton Utah, Warren Michigan, Spokane Washington, Buffalo New York, Rochester New York, Iowa City Iowa, Akron Ohio, Columbus Georgia, Green Bay Wisconsin, Jacksonville Florida, New York New York, Bowling Green Kentucky, Cleveland Ohio, Caldwell Idaho, Mesa Arizona, Austin Texas, Dallas Texas, Fort Worth Texas, Houston Texas, Sterling Heights Michigan, Detroit Michigan, Seattle Washington, Kearney Nebraska, Davenport Iowa, Cincinnati Ohio, Atlanta Georgia, Kenosha Wisconsin, Scottsdale Arizona, Albuquerque New Mexico, Tacoma Washington, Omaha Nebraska, Cedar Rapids Iowa, Macon Georgia, Madison Wisconsin, Meridian Idaho, Phoenix Arizona, Chandler Arizona, Tucson Arizona, San Antonio Texas, Las Cruces New Mexico, Orem Utah, Tampa Florida, Owensboro Kentucky, Lexington-Fayette Kentucky, Louisville Kentucky, Sioux City Iowa, Racine Wisconsin, Nampa Idaho, Idaho Falls Idaho, Santa Fe New Mexico, West Valley City Utah, Provo Utah, Orlando Florida, Dayton Ohio, Augusta Georgia, Milwaukee Wisconsin, Boise Idaho, Roswell New Mexico, Bellevue Washington, Vancouver Washington, St. Petersburg Florida, Bellevue Nebraska, Lincoln Nebraska, Grand Island Nebraska, Savannah Georgia 04/15/2025
- Manager, Medical Economics (Marketplace) - REMOTE Albany New York, Everett Washington, Idaho, Iowa, Kentucky, Florida, Michigan, New York, Georgia, Texas, Wisconsin, Ohio, Washington, New Mexico, Roswell New Mexico, Nebraska, Utah, Spokane Washington, Tampa Florida, Racine Wisconsin, Milwaukee Wisconsin, Idaho Falls Idaho, Grand Rapids Michigan, Buffalo New York, Bellevue Nebraska, Grand Island Nebraska, Phoenix Arizona, Santa Fe New Mexico, Albuquerque New Mexico, Orem Utah, Warren Michigan, Orlando Florida, Louisville Kentucky, Cincinnati Ohio, Columbus Georgia, Atlanta Georgia, Madison Wisconsin, Austin Texas, Las Cruces New Mexico, West Valley City Utah, Layton Utah, Miami Florida, New York New York, Omaha Nebraska, Boise Idaho, Meridian Idaho, Mesa Arizona, Rio Rancho New Mexico, Ann Arbor Michigan, Yonkers New York, Owensboro Kentucky, Lexington-Fayette Kentucky, Kearney Nebraska, Davenport Iowa, Des Moines Iowa, Cleveland Ohio, Columbus Ohio, Savannah Georgia, Chandler Arizona, Scottsdale Arizona, San Antonio Texas, Dallas Texas, Fort Worth Texas, Salt Lake City Utah, Bellevue Washington, Seattle Washington, Vancouver Washington, Rochester New York, Covington Kentucky, Sioux City Iowa, Dayton Ohio, Kenosha Wisconsin, Nampa Idaho, Tacoma Washington, St. Petersburg Florida, Syracuse New York, Bowling Green Kentucky, Lincoln Nebraska, Cedar Rapids Iowa, Akron Ohio, Macon Georgia, Houston Texas, Detroit Michigan, Jacksonville Florida, Iowa City Iowa, Augusta Georgia, Green Bay Wisconsin, Caldwell Idaho, Tucson Arizona, Provo Utah, Sterling Heights Michigan, Long Beach California 04/14/2025
No recently viewed jobs.
View All JobsNo saved jobs.
View All Jobs