RN CASE MANAGER: Care Transition CALIFORNIA

$63,170 - $123,157/Yr

Molina Healthcare - Temecula, CA

Full-time

Temecula, CA

Insurance Carriers and Related Activities

About the position

The position involves working with Molina Healthcare Services to coordinate care for members with high needs, ensuring safe transitions from hospital to home or other care settings. The role focuses on reducing readmissions through effective communication and collaboration with various healthcare providers and support networks, while also educating members on their care plans and needs.

Responsibilities

• Follow members throughout a 30-day program starting at hospital admission and continuing through transitions to other settings.
• Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and family/support networks to ensure safe transitions.
• Ensure members transition to settings with adequate caregiving and functional support, as well as medical and medication oversight.
• Work with ancillary providers and public agencies to ensure necessary services and equipment are in place for safe transitions.
• Conduct face-to-face visits of all members while in the hospital and home visits of high-risk members post-discharge.
• Coordinate care and reassess member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
• Educate and support members focusing on seven primary areas: medication management, personal health record use, follow-up care, signs of worsening condition, nutrition, functional needs, and advance directives.
• Use motivational interviewing and Molina clinical guideposts to educate and motivate change during member contacts.
• Assess barriers to care and provide care coordination and assistance to address concerns.
• Facilitate interdisciplinary care team meetings and informal ICT collaboration.
• Provide consultation, recommendations, and education as appropriate to non-RN case managers.
• Conduct medication reconciliation when needed.

Requirements

• Graduate from an Accredited School of Nursing.
• Active, unrestricted State Registered Nursing (RN) license in good standing.
• 1-3 years of experience in hospital discharge planning or home health.
• Valid driver's license with a good driving record and reliable transportation.

Nice-to-haves

• Bachelor's Degree in Nursing (preferred).
• 3-5 years of experience in hospital discharge planning or home health (preferred).
• Active, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM) (preferred).

Benefits

• Competitive benefits and compensation package.