Telephonic Transition of Care Coach; RN - Reside

Telephonic Transition of Care Coach (RN) - Must Reside in Texas

Opportunity for TX licensed RN to join our DSNIP team to work with our members who are hospitalized and ready to be discharged. The RN hired for this position will work with the hospital discharge team to make sure that all the appropriate resources, doctor appointments, etc. are ready so that the transition out of the facility occurs smoothly. This position is fully remote, working from home, but there may be future field assessments on caseload members.

Preference will be given to candidates with experience working as a Transition of Care Coach with another MCO like Molina. Additional pluses – experience with the LTSS or Behavioral Health populations. Bilingual is also a plus. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.

Job Summary

Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at the time of hospital discharge and focuses on reducing member readmissions.

Essential Job Duties

• Follows member throughout a 30‑day program starting at hospital admission and continues oversight through transitions to all other settings, including nursing facility placement/private home.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight support.
• Works with 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 in the hospital and home visits for high‑risk members post‑discharge as needed.
• Coordinated care and reassesses member needs using the Coleman Care Transition model post‑discharge.
• Educates and supports member focusing on the seven primary areas of the Transition of Care Pillars: medication management, use of personal health record, follow‑up care, signs and symptoms of worsening condition, nutrition, functional needs, home/community‑based services, and advance directives.
• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.
• Assesses barriers to care, provides care coordination and assistance to address concerns.
• Facilitates interdisciplinary care team meetings and collaboration.
• Provides consultation, recommendations and education as appropriate to non‑behavioral health care managers.
• May require 40‑50% local travel.

Required Qualifications

• At least 2 years of experience in health care, with at least 1 year in hospital discharge planning, care management or behavioral health settings.
• Registered Nurse (RN) with an active, unrestricted license in Texas.
• Valid, unrestricted driver’s license with 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, detail‑oriented, and able to work independently with minimal supervision.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office Suite and other applicable software.

Preferred Qualifications

• Transitions of care sub‑specialty certification and/or Certified Case Manager (CCM).
• Hospital discharge planning or home health experience.

Compensation

Hourly pay range: $26.41 – $51.49 per hour. Actual compensation may vary based on geographic location, experience, education and skill level.

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.