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2h ago Curated

Transition of Care Coach (RN) - King/Pierce County, WA

Molina Healthcare

Job description

Hybrid day-shift RN Care Manager position supporting Medicaid members across hospitals in King, Pierce, Snohomish, Kitsap, and Clark Counties. This field-based role requires approximately 75% travel and focuses on case management, discharge planning, and care coordination to ensure members receive appropriate healthcare services and support. Follows member throughout a 30-day program starting at hospital admission, overseeing transitions to nursing facility or home with goal of reduced readmissions. Conducts face-to-face visits in hospital and home visits post-discharge as needed. Uses Coleman Care Transition model, motivational interviewing, and coordinates care with providers and community resources.

Key responsibilities

  • Follow member through 30-day transition program from hospital admission to discharge
  • Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family
  • Conduct face-to-face visits in hospital and home visits for high-risk members post-discharge
  • Educate and support member on medication management, follow-up care, signs/symptoms, nutrition, functional needs, advance directives
  • Assess barriers to care and provide care coordination
  • Facilitate interdisciplinary care team meetings

What you bring

  • Active RN license in Washington
  • 2+ years healthcare experience with 1+ year in discharge planning, care management, or behavioral health
  • Valid driver's license, reliable transportation, auto insurance
  • Knowledge of Care Transitions Intervention (CTI) or similar model
  • Background in discharge planning and/or home health
  • Proficiency in Microsoft Office

Tags

Field-basedCare TransitionsMedicaidWashington State

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