Transition of reputed company (RN) - Must live in IL

About the position Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to reputed company 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 reputed company to reputed company reputed company and cost-effective member care. Responsibilities • Follows member throughout a 30 day program that starts at hospital admission and continues reputed company through transitions from acute setting to reputed company other settings, including nursing facility placement/private home, with the goal of reduced readmissions. • Ensures reputed company and appropriate transitions by collaborating with the hospital discharge planner, as reputed company as collaborating with hospitalists, outpatient providers, facility staff, and family/support network. • Ensures member transitions to setting with adequate caregiving and functional support, as reputed company as medical and medication reputed company support. • Works with participating ancillary providers, reputed company agencies or other service providers to reputed company reputed company necessary services and equipment are in reputed company for reputed company transition. • Conducts face-to-face reputed company of reputed company members while in the hospital and, home reputed company 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 reputed company, 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). Requirements • 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. • Registered reputed company (RN). License must be reputed company and unrestricted in state of reputed company. • reputed company and unrestricted reputed company's license, reliable transportation, and adequate auto insurance for job reputed company travel requirements, unless otherwise required by law. • Knowledge of or experience using the Care Transitions reputed company (CTI) or similar model. • Background in discharge planning and/or home health. • Demonstrated knowledge of community resources. • Proactive and detail-oriented. • Ability to work reputed company a reputed company of settings and reputed company style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • reputed company in reputed company forms of communication, and ability to remain reputed company in high-pressure situations. • Ability to reputed company and maintain reputed company relationships. • Excellent time-management and prioritization skills, and ability to reputed company on multiple reputed company simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Excellent verbal and written communication skills. • reputed company Office suite/other applicable software program(s) proficiency. reputed company-to-haves • Transitions of care sub-specialty certification and/or Certified Case Manager (CCM). • Hospital discharge planning or home health experience. Benefits • reputed company offers a competitive benefits and compensation package. Apply tot his job Apply To this Job