Care Transition Registered Nurse

Job Summary The Care Transition Coach (RN) plays a vital role in guiding members through their journey from hospital to various care settings. This position emphasizes facilitating seamless transitional care processes to ensure that members receive optimal services at the time of their hospital discharge, ultimately aiming to reduce readmissions and enhance overall care quality. We are looking for committed individuals with an active RN license in Massachusetts and experience in managed care or case management, especially related to transition of care. The ideal candidate should have a background in hospital settings and exhibit exceptional communication, documentation, and electronic medical record (EMR) skills. We encourage bilingual candidates to apply to effectively serve our diverse communities! Work Hours: Monday - Friday 8:00am - 5:00pm EST This is a remote position involving field travel in Bristol, Plymouth, Essex, Norfolk, Suffolk, or Middlesex County, MA. Essential Job Duties Monitor members throughout a 30-day care transition program, starting from hospital admission to safe transitions into various settings, whether home or nursing facilities, with an emphasis on minimizing readmissions. Collaborate closely with hospital discharge planners, hospitalists, outpatient providers, facility staff, and families to ensure safe and effective transitions. Assess members' needs and implement appropriate support, caregiving, and medication oversight during transitions. Coordinate necessary services and equipment by liaising with ancillary providers and public agencies. Conduct face-to-face visits with all members while in the hospital and perform home visits for high-risk post-discharge members as needed. Utilize the Coleman Care Transition model to reassess member needs and coordinate ongoing care following discharge. Educate members on crucial areas essential for successful care transitions, including medication management, follow-up care, and advance directives. Employ motivational interviewing techniques to support and empower members toward effective health management. Identify and address barriers to care, ensuring thorough coordination and assistance for members. Facilitate interdisciplinary care team meetings to promote collaboration among healthcare professionals. Provide valuable insights and education to non-behavioral health care managers when appropriate. Be prepared for 40-50% local travel as per state and contractual requirements. Required Qualifications Minimum of 2 years in healthcare, with at least 1 year in hospital discharge planning, care management, or a related equivalent. Registered Nurse (RN) with an active, unrestricted license in Massachusetts. Valid driver's license and reliable transportation for job-related travel. Familiarity with the Care Transitions Intervention (CTI) model or similar frameworks. Experience in discharge planning or home health. Strong knowledge of community resources. Proactive, detail-oriented, and adaptable to diverse populations and personal situations. Independently motivated with strong communication and problem-solving abilities. Proficient in Microsoft Office Suite and other relevant software. Preferred Qualifications Certification in Transitions of Care or Certified Case Manager (CCM). Prior experience in hospital discharge planning or home health. Molina Healthcare offers a competitive compensation and benefits package. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $30.37 - $59.21 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and skill level.

Created: 2026-03-04