Transitions of Care Registered Nurse in Nampa, ID

Molina Healthcare Services

Molina Healthcare Services (HCS) collaborates with members, providers, and multidisciplinary teams to assess, facilitate, plan, and coordinate seamless care delivery across various settings, including behavioral health and long-term care, particularly for members with high needs. Our HCS staff is dedicated to ensuring that patients achieve their desired health outcomes through quality, medically appropriate, and cost-effective care tailored to the severity of their illness and their service location.

Key Responsibilities:
• Guide members throughout a 30-day program starting from hospital admission, ensuring continuous support during transitions from acute care to other settings, including nursing facilities or private homes, aiming to reduce readmissions.
• Collaborate with hospital discharge planners, hospitalists, outpatient providers, facility staff, and members' family/support networks to ensure safe and effective transitions.
• Assist members in transitioning to environments that provide adequate caregiving and support, along with necessary medical and medication oversight.
• Engage with participating ancillary providers and public agencies to ensure necessary services and equipment are in place for safe transitions.
• Conduct face-to-face visits for all members while hospitalized and follow up with high-risk members post-discharge through home visits.
• Coordinate care and assess members' needs using the Coleman Care Transitions Model for post-discharge follow-up.
• Educate and support members across seven primary areas (ToC Pillars): medication management, personal health record use, follow-up care, signs of worsening conditions, nutrition, functional needs or Home and Community-based Services, and advanced directives.
• Utilize motivational interviewing and Molina clinical guideposts to inform and empower members in their healthcare journey.
• Identify and address barriers to care while providing comprehensive care coordination and assistance to members.
• Lead interdisciplinary care team discussions and informal collaborations among the care team.
• Provide guidance, insights, and educational support to non-RN case managers as needed.
• Handle cases involving members with complex medical conditions and intricate medication regimens, conducting medication reconciliation when necessary.
• Expect approximately 40-50% local travel as part of the role.

Job Qualifications:

Required Education: Graduate from an Accredited School of Nursing. A Bachelor's Degree in Nursing is preferred.

Required Experience: 1-3 years in hospital discharge planning or home health settings.

Required License and Certification:
• Active and unrestricted State Registered Nursing (RN) license in good standing.
• Valid driver's license with a clean driving record and ability to drive reliably.

Preferred Education: Bachelor's Degree in Nursing.

Preferred Experience: 3-5 years in hospital discharge planning or home health.

Preferred License and Certification: Active, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM).

If you are a current Molina employee, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $23.76 - $51.49 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and skill level.

About Us: Molina Healthcare is dedicated to providing quality healthcare to individuals receiving government assistance. Join our passionate, team-oriented workforce and make a difference in the lives of others. We offer a comprehensive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.