Transition of Care RN

Habitat Health•California, CA

1d•$48 - $77•Remote

About The Position

Habitat Health empowers older adults to experience more good days in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive medical care along with support for daily needs such as meals, transportation, and in‑home assistance. We deliver coordinated clinical and social care in our centers and directly in participants’ homes, creating a fully integrated experience that brings peace of mind and a true sense of belonging. As we expand our scalable, affordable PACE model to meet the growing and complex needs of aging populations, our mission‑driven care teams continue to help participants live well on their own terms. Habitat Health is supported by leading healthcare organizations and investors including New Enterprise Associates, Kaiser Permanente, and Town Hall Ventures. We are entering a period of significant growth and are looking for exceptional teammates to help us scale a better model of care for older adults. To learn more, visit www.habitathealth.com.

Requirements

Active Registered Nurse (RN) licensure in California (or compact license with California authorization)
2–3 years of clinical nursing experience, with 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, 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
Ability to work flexible hours, including occasional evenings or weekends, to align with discharge timing
Bilingual skills (Spanish or other languages reflective of participant communities)

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 within 6 months of employment
Experience with EPIC

Responsibilities

Initiate and manage discharge planning for PACE participants admitted to hospitals, skilled nursing facilities (SNFs), or the emergency department
Coordinate with inpatient care teams, IDT members, and external network providers to facilitate smooth, timely transitions back to home or community settings
Ensure all post-discharge services — including transportation, DME, home health, medications, home care, and follow-up appointments — are arranged and confirmed prior to discharge
Monitor participants post-discharge through proactive outreach and follow-up calls to assess status, identify concerns, and support care plan adherence
Identify and address social determinants of health (SDOH) and other barriers that may 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
Serve as the primary point of contact between inpatient facilities and the PACE IDT during acute and post-acute transitions
Serve as the primary point of contact for network providers during post discharge care coordination
Document all transition-related activities and care coordination efforts accurately and in a timely manner in the electronic health record (EHR)
Communicate participant updates and discharge plans to IDT members, participants, and families.
Provide health coaching and education to participants/caregiver on discharge summary plan of care.
Participate in IDT meetings, care conferences, and readmission review processes as needed
Track and report on key transitions of care metrics, including length of stay, readmission rates, and discharge destination
Support quality improvement initiatives aimed at reducing avoidable hospitalizations, ensuring appropriate length of stay, and improving careafter transition outcomes
Maintain compliance with state and federal regulations, and Habitat Health policies and procedures