Qualified candidate must live in Southern CALIFORNIAnnJOB DESCRIPTIONnnJob SummarynnMolina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.nnKNOWLEDGE/SKILLS/ABILITIESnnFollows 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.nnEnsures 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.nnEnsures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required.nnWorks with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.nnConducts face-to-face visits of all members while in the hospital and home visits of high-risk members post-discharge.nnCoordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.nnEducates 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.nnUses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.nnAssesses for barriers to care, provides care coordination and assistance to member to address concerns.nnFacilitates interdisciplinary care team meetings and informal ICT collaboration.nnRNs provide consultation, recommendations, and education as appropriate to non-RN case managers.nnRNs are assigned cases with members who have complex medical conditions and medication regimens.nnRNs will conduct medication reconciliation when needed.nn40-50% local travel required.nnJOB QUALIFICATIONSnnRequired EducationnnGraduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred.nnRequired Experiencenn1-3 years hospital discharge planning or home health.nnRequired License, Certification, AssociationnnActive, unrestricted State Registered Nursing (RN) license in good standing.nnMust have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.nnPreferred EducationnnBachelor's Degree in NursingnnPreferred Experiencenn3-5 years hospital discharge planning or home health.nnPreferred License, Certification, AssociationnnActive, unrestricted Transitions of Care Sub-Specialty Certification and/or Certified Case Manager (CCM)nnTo all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.nnMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.nnPay Range: $30.37 - $59.21 / HOURLYnn*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.