Transition of Care Coordinator, LVN (Home Care)
About The Position
The Transition of Care (TOC) Coordinator at High Desert PACE is a pivotal clinical role dedicated to bridging the gap between acute care settings and the home environment. As an LVN in this role, you will facilitate the seamless, safe, and coordinated movement of PACE participants across the continuum of care including hospitals, skilled nursing facilities (SNF), PACE centers, and private residences. Your mission is to ensure that no participant "falls through the cracks" during a transition. By providing rigorous clinical oversight, medication reconciliation, and caregiver education, you will promote participant independence, reduce avoidable readmissions, and uphold the integrated care model that defines High Desert PACE.
Requirements
- Current, valid California Licensed Vocational Nurse (LVN) license.
- Associate degree in nursing or a related clinical field.
- Minimum of 3+ years of experience in care coordination, transitional care, case management, or home health.
- Strong proficiency in medication reconciliation and chronic disease management.
- Exceptional interpersonal communication, the ability to remain calm under pressure, and a high degree of organizational autonomy.
- Valid CA Driver’s License and reliable transportation (for home visits and facility rounding).
Nice To Haves
- Specific experience with the geriatric population and/or dual-eligible (Medicare/Medi-Cal) populations is highly preferred.
Responsibilities
- Serve as the primary point of contact between hospital/SNF discharge planners and the PACE Interdisciplinary Team (IDT).
- Attend discharge planning meetings to ensure the home environment is prepared for the participant’s return.
- Visit participants in acute or post-acute facilities to assess clinical status and begin the transition planning process before they leave the facility.
- Build and maintain strong professional relationships with local High Desert hospitals and rehab centers to ensure timely notification of participant admissions and discharges.
- Perform comprehensive medication reconciliation post-discharge, identifying discrepancies between hospital orders and the current PACE care plan to prevent adverse drug events.
- Conduct telephonic or in-person follow-up assessments within 48 hours of discharge to monitor stability, symptom management, and adherence to the updated care plan.
- Schedule and ensure transportation for all necessary follow-up appointments with PACE primary care providers or specialty consultants.
- Educate participants and their families on red flag symptoms related to their specific diagnoses (e.g., CHF, COPD, Diabetes) and provide clear instructions on who to call if symptoms escalate.
- Train caregivers on new equipment, wound care basics, or medication administration techniques required post-discharge.
- Actively participate in daily IDT meetings, providing real-time updates on hospitalized participants and proposing modifications to the Life Plan based on transitional needs.
- Accurately track and report on transition metrics, including 30-day readmission rates and Time to First Follow-up to support PACE quality improvement initiatives.
- Maintain meticulous electronic health record (EHR) documentation in accordance with CMS and DHCS standards for PACE organizations.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
