RN - TX Licensure - Transition of Care Coach

Company: Molina Healthcare
Location: Waukesha
Posted on: March 12, 2025

Job Description:

**For this position we are seeking a (RN) Registered Nurse who must have a current active unrestricted RN license in the state of TEXAS.JOB DESCRIPTIONJob SummaryMolina 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 telephonic visits of all members while in the hospital 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.JOB QUALIFICATIONSRequired EducationGraduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.Required Experience1-3 years hospital discharge planning or home health.Required License, Certification, Association
  • 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 EducationBachelor's Degree in NursingPreferred Experience3-5 years hospital discharge planning or home health.Preferred License, Certification, AssociationActive, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM)This role is currently 100% remoteHome office with internet connectivity of high speed required.Schedule: Monday thru Friday 8:00AM to 5:00PM CENTRAL TIME ZONE (No weekends or Holidays)**Candidates who do not live in Texas must be willing to work TEXAS CENTRAL Business hours.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: $26.41 - $61.79 / HOURLY
    *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.Required
    Preferred

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Keywords: Molina Healthcare, Waukesha , RN - TX Licensure - Transition of Care Coach, Education / Teaching , Waukesha, Wisconsin