Transition of Care RN

Habitat Health•California, CA

1d•$48 - $77•Remote

About The Position

The Transition of Care RN is a centralized, remote role within Habitat Health’s Clinical Operations team. The RN manages acute discharge planning and transitions-of-care case management for PACE participants across the organization’s centers. Serving as a clinical liaison during hospitalizations, skilled nursing facility stays, and emergency department visits, the nurse coordinates safe and timely transitions back to the community. The role works closely with interdisciplinary care teams, facility staff, and community partners to minimize care gaps, reduce length of stay and avoidable readmissions, and support participants’ individual goals and preferences. The position follows Pacific Time and is scheduled Sunday–Thursday or Tuesday–Saturday, 8:00 a.m.–5:00 p.m. It also requires flexibility for on-call and overtime coverage during shoulder hours, 5:00–7:00 p.m. PST.

Requirements

Active Registered Nurse (RN) license in California, or a compact license with California authorization.
2–3 years of clinical nursing experience, including at least 1 year in case management, discharge planning, or transitions of care.
Experience working with complex, medically frail, or older adult populations.
Strong knowledge of acute care and post-acute care settings and community-based resources.
Proficiency with electronic health record systems.
Excellent communication, critical-thinking, and organizational skills.
Ability to work independently and collaboratively in a remote, fast-paced environment.
Availability Sunday–Thursday or Tuesday–Saturday, 8:00 a.m.–5:00 p.m. PST, with flexibility for on-call and overtime coverage from 5:00–7:00 p.m. PST.

Nice To Haves

Experience in a PACE program, managed care, or value-based care setting.
Familiarity with Medicare and Medi-Cal regulations.
Case management certification (CCM), or willingness to obtain it within 6 months of employment.
Experience with EPIC.
Bilingual skills in Spanish or other languages reflective of participant communities.

Responsibilities

Initiate and manage discharge planning for PACE participants admitted to hospitals, skilled nursing facilities, or emergency departments.
Coordinate with inpatient care teams, interdisciplinary care team (IDT) members, and external network providers to facilitate transitions back to home or community settings.
Arrange and confirm post-discharge services before discharge, including transportation, durable medical equipment, home health, medications, home care, and follow-up appointments.
Conduct proactive post-discharge outreach and follow-up calls to assess participant status, identify concerns, and support care plan adherence.
Identify and address social determinants of health and other barriers that could complicate transitions or increase readmission risk.
Collaborate with the IDT to update care plans and communicate changes in participant status or needs.
Transition care back to the empaneled IDT following discharge.
Act as the primary contact between inpatient facilities and the PACE IDT during acute and post-acute transitions, and for network providers during post-discharge coordination.
Document transition-related activities and care coordination accurately and promptly in the electronic health record.
Communicate participant updates and discharge plans to IDT members, participants, and families.
Provide participants and caregivers with health coaching and education about the discharge summary plan of care.
Participate in IDT meetings, care conferences, and readmission review processes as needed.
Track and report transitions-of-care metrics, including length of stay, readmission rates, and discharge destination.
Support quality improvement initiatives to reduce avoidable hospitalizations, ensure appropriate length of stay, and improve outcomes after transitions.
Maintain compliance with state and federal regulations and Habitat Health policies and procedures.