Skip to content
RemoteRN
Post a job
9h ago Curated

Transition of Care Coach (RN) Remote (Michigan)

Molina Healthcare

Job description

This RN acts as a Transition of Care Coach supporting Michigan Medicare and Dual members recently admitted to the hospital. The role involves phone outreach and virtual meetings with members while still inpatient, ensuring safe transitions from inpatient to nursing facility or home. Duties include following members through a 30-day program, collaborating with hospital discharge planners and providers, conducting telephonic virtual visits, coordinating care using the Coleman Care Transition model, educating members on medication management and follow-up care, and facilitating interdisciplinary care team meetings. 40-50% local travel may be required. Requires active unrestricted RN license in Michigan, 2+ years healthcare experience with 1+ year in hospital discharge planning, care management, or behavioral health in a remote setting, and knowledge of Care Transitions Intervention model.

Key responsibilities

  • Follow member through 30-day program from hospital admission through transitions
  • Collaborate with hospital discharge planner, hospitalists, outpatient providers, facility staff, and family
  • Conduct telephonic virtual visits of members while in hospital and high-risk members post-discharge
  • Coordinate care and reassess needs using Coleman Care Transition model
  • Educate members on medication management, personal health record, follow-up care, etc.
  • Facilitate interdisciplinary care team meetings
  • Assess barriers to care and provide care coordination

What you bring

  • Active unrestricted RN license in Michigan
  • 2+ years healthcare experience with 1+ year in hospital discharge planning, care management, or behavioral health in remote setting
  • Knowledge of Care Transitions Intervention (CTI) or similar model
  • Background in discharge planning and/or home health
  • Proficient in Microsoft Office suite
  • Valid driver's license and reliable transportation

Tags

RemoteMichiganTransition of CareCase ManagementRN

Related roles

More open case management positions — or browse every case management role.