Molina Healthcare

Transition of Care Coach (RN): UPSTATE South Carolina

Posted on: 27 Mar 2021

Cayce, SC

Job Description

For this position, we are seeking a RN (Registered Nurse) who can travel within UPSTATE SOUTH CAROLINA, AIKEN COUNTY area. Must be licensed as a RN for the state of South Carolina and must live in one of the above mentioned areas in South Carolina. This position will require travel to facilities and members' homes. At this time our staff are not travelling in the field due to COVID measures. We will resume field travel when it is safe to do so.

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.
40-50% local travel 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
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
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.

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: 03/19/2021

Molina Healthcare

Long Beach, CA

Molina Healthcare, Inc., a multi-state healthcare organization, provides managed health care services to low-income families and individuals under the Medicaid and Medicare programs and through the state insurance marketplaces. As of December 31, 2018, it served approximately 3.8 million members in 14 states and the Commonwealth of Puerto Rico, who are eligible for Medicaid, Medicare, and other government-sponsored health care programs. The company offers its health care services for its members through contracts with a network of providers, including physicians and physician groups, hospitals, ancillary providers, and pharmacies. Molina Healthcare, Inc. was founded in 1980 and is headquartered in Long Beach, California.

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