Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support
Assesses for barriers to care, provides care coordination and assistance to member to address concerns
40-50% local travel may be required (based upon state/contractual requirements)
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
Conducts face-to-face visits of all members while in the hospital and, home visits high-risk members post-discharge as needed
Background in discharge planning and/or home health
Ability to develop and maintain professional relationships
Strong communication, documentation, and EMR skills
Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law
Work Hours: Monday - Friday 8:00am - 5:00pm EST
Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations
Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition
At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, or equivalent combination of relevant education and experience
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
Microsoft Office suite/other applicable software program(s) proficiency
Remote position with field travel in Plymouth, Essex, Norfolk, Suffolk or Middlesex county MA
Registered Nurse (RN). License must be active and unrestricted in state of practice
Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model
Excellent problem-solving, and critical-thinking skills
Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge
Bilingual candidates are encouraged to apply to support our diverse communities
Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change
Facilitates interdisciplinary care team meetings (ICT) and collaboration
Prior work history with a managed care plan or case management experience, preferably transition of care
Proactive and detail-oriented
Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts
Provides consultation, recommendations and education as appropriate to non- behavioral health care managers
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
Ability to work independently, with minimal supervision and demonstrate self-motivation
Demonstrated knowledge of community resources
MA RN licensure
Responsive in all forms of communication, and ability to remain calm in high-pressure situations
Hospital experience required
Excellent verbal and written communication skills