Healthcare - Transition of Care Registered Nurse

Job Title

Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions. Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member. Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required. Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition. Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members' post-discharge. Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline. Educates and supports member focusing on seven primary areas (ToC 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 and informal ICT collaboration. RNs provide consultation, recommendations, and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens. RNs will conduct medication reconciliation when needed. 5-10% local travel required.

Top skills required: discharge planning experience, motivational interviewing, team player.

Required education/certification(s): registered nurse.

Required years of experience: 3-5 minimum.

Standard equipment + dual monitors & docking station.

Must reside in San Diego County, CA. Remote position but will require some travel. Must have a valid CA Driver's License.