Transition of Care Coach (RN) Remote (Must Reside in Michigan)

Job Description

This RN will act as a Transition of Care Coach supporting our Michigan Medicare and Dual members who have recently been admitted to this hospital. The TOC Coach 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 virtual 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. Outreaching PCC members and working independently.

Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.

Schedule: Monday through Friday 8:30AM to 5:00PM EST (No weekends, no nights, no holidays, no call.)

Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to provide quality and cost-effective member care.

Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions. Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network. Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support. Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition. Conducts telephonic virtual visits of all members while in the hospital and, high-risk members post-discharge as needed. Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge. Educates and supports member focusing on seven primary areas (Transition of Care Pillars): medication management, use of personal health record, follow-up care, signs and symptoms of worsening condition, nutrition, functional needs and or home and community-based services, and advance directives. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. Facilitates interdisciplinary care team meetings (ICT) and collaboration. Provides consultation, recommendations and education as appropriate to non-behavioral health care managers. 40-50% local travel may be required (based upon state/contractual requirements).

At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management, case management, or behavioral health in a remote setting, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model. Background in discharge planning and/or home health. Demonstrated knowledge of community resources. Proactive and detail-oriented. Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. Ability to work independently, with minimal supervision and demonstrate self-motivation. Responsive in all forms of communication, and ability to remain calm in high-pressure situations. Ability to develop and maintain professional relationships. Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. Excellent problem-solving, and critical-thinking skills. Excellent verbal and written communication skills. Microsoft Office suite/other applicable software program(s) proficiency.

Transitions of care sub-specialty certification and/or Certified Case Manager (CCM). Hospital discharge planning or home health experience.