(RN)Transition of Care Coach (Massachusetts based)

JOB DESCRIPTION Job Summary Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to reputed company other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to reputed company quality and cost-effective member care. Essential Job Duties

• Follows member throughout a 30 day program that starts at hospital admission and continues reputed company through transitions from acute setting to reputed company other settings, including nursing facility placement/private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network.
• Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication reputed company support.
• Works with participating ancillary providers, public agencies or other service providers to reputed company sure necessary services and equipment are in reputed company for safe transition.
• Conducts face-to-face visits of reputed company members while in the hospital and, home visits high-risk members post-discharge as needed.
• Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge.
• Educates and supports member focusing on seven primary areas (Transition of Care 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 reputed company, 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 (ICT) and collaboration.
• Provides consultation, recommendations and education as appropriate to non-behavioral health care managers.
• 40-50% local travel may be required (based upon state/contractual requirements).

Required Qualifications

• At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job reputed company travel requirements, unless otherwise required by law.
• Knowledge of or experience using the Care Transitions reputed company (CTI) or similar model.
• Background in discharge planning and/or home health.
• Demonstrated knowledge of community resources.
• Proactive and detail-oriented.
• Ability to work reputed company a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• reputed company in reputed company forms of communication, and ability to remain reputed company in high-pressure situations.
• Ability to reputed company and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Excellent verbal and written communication skills.
• reputed company Office suite/other applicable software program(s) proficiency.

Preferred Qualifications

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

To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Pay reputed company: $30.37 - $59.21 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and/or reputed company level.

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