Transition of Care Coach, LTSS (RN) - Local Travel ...

JOB DESCRIPTION We are seeking TX licensed Registered Nurses who live in either the Dallas, Fort Worth, or Houston service delivery areas. This RN will act as a Transition of Care Coach supporting our TX Medicaid members who have recently been admitted to a local hospital. The TOCC will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus. TRAVEL in the field to designated hospitals in the local service delivery area to meet with the members. Mileage is reimbursed as part of our benefit package. Schedule: Monday through Friday 8:00AM to 5:00PM CST (No weekends, no nights, no holidays, no call.) Job Summary Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties u2022 Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. u2022 Facilitates comprehensive waiver enrollment and disenrollment processes. u2022 Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. u2022 Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. u2022 Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. u2022 Assesses for medical necessity and authorizes all appropriate waiver services. u2022 Evaluates covered benefits and advises appropriately regarding funding sources. u2022 Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. u2022 Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. u2022 Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. u2022 Identifies critical incidents and develops prevention plans to assure member health and welfare. u2022 May provide consultation, resources and recommendations to peers as needed. u2022 Care manager RNs may be assigned complex member cases and medication regimens. u2022 Care manager RNs may conduct medication reconciliation as needed. u2022 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications u2022 At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience. u2022 Registered Nurse (RN). License must be active and unrestricted in state of practice. u2022 Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. u2022 Ability to operate proactively and demonstrate detail-oriented work. u2022 Demonstrated knowledge of community resources. u2022 Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. u2022 Ability to work independently, with minimal supervision and demonstrate self-motivation. u2022 Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. u2022 Ability to develop and maintain professional relationships. u2022 Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. u2022 Excellent problem-solving and critical-thinking skills. u2022 Strong verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. u2022 In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications u2022 Certified Case Manager (CCM). u2022 Experience working with populations that receive waiver services. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2026-02-23