Care Transition Nurse

Job Summary The Care Transition Nurse plays a crucial role in supporting members as they move from hospital care to various other settings. This position focuses on ensuring smooth transitions in care to help members receive the best services upon discharge from the hospital, aiming to reduce readmissions and improve overall quality of care. We are seeking dedicated professionals with an active RN license in Massachusetts and experience in managed care or case management, especially in care transitions. The ideal candidate will have a background in hospital settings and demonstrate excellent communication, documentation, and electronic medical record (EMR) skills. Bilingual candidates are encouraged to apply to better serve our diverse communities! Work Hours: Monday - Friday 8:00am - 5:00pm EST This is a remote position requiring travel in Bristol, Plymouth, Essex, Norfolk, Suffolk, or Middlesex County, MA. Essential Job Duties Oversee members during a 30-day care transition program, starting from hospital admission to safe transitions into various settings, such as home or nursing facilities, with a strong focus on minimizing readmissions. Work closely with hospital discharge planners, hospitalists, outpatient providers, facility staff, and families to ensure effective and safe transitions. Assess members' needs and coordinate appropriate support, caregiving, and medication management during transitions. Facilitate necessary services and equipment by communicating with ancillary providers and public agencies. Conduct in-person visits with all members while in the hospital and perform home visits for high-risk post-discharge members as necessary. Apply the Coleman Care Transition model to reassess member needs and coordinate ongoing care after discharge. Educate members on critical areas necessary for successful transitions, including medication management, follow-up care, and advance directives. Utilize motivational interviewing techniques to support and empower members towards effective health management. Identify and resolve barriers to care, ensuring thorough coordination and assistance for members. Facilitate interdisciplinary care team meetings to enhance collaboration among healthcare professionals. Offer valuable insights and education to non-behavioral health care managers when appropriate. Be prepared for 40-50% local travel as per state requirements and contractual obligations. Required Qualifications At least 2 years of healthcare experience, including a minimum of 1 year in hospital discharge planning, care management, or a related field. Registered Nurse (RN) with an active, unrestricted license in Massachusetts. Valid driver's license and reliable transportation for work-related travel. Familiarity with the Care Transitions Intervention (CTI) model or similar frameworks. Experience in discharge planning or home health settings. Strong knowledge of community resources. Proactive, detail-oriented, and adaptable to diverse populations and personal situations. Self-motivated with excellent communication and problem-solving skills. Proficient in Microsoft Office Suite and other relevant software. Preferred Qualifications Certification in Transitions of Care or Certified Case Manager (CCM). Previous experience in hospital discharge planning or home health. Molina Healthcare offers a competitive compensation and benefits package. We pride ourselves on being 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: 2026-03-13