Transition of Care RN

Role Scope: 

The Transitions of Care RN is a centralized, remote role within the Clinical Operations team, responsible for managing acute discharge planning and transitions of care case management for PACE participants across Habitat Health's Centers. This nurse serves as a key clinical liaison during care transitions — including acute/unplanned hospitalizations, skilled nursing facility stays, and emergency department visits — ensuring safe, timely, and well-coordinated returns to the community. The Transitions of Care RN partners closely with interdisciplinary care teams (IDTs), inpatient facility staff, and community partners to minimize gaps in care, reduce length of stay, prevent avoidable readmissions, and support each participant's individual goals and preferences. 

Hours/Location:

• Remote role (will need to follow Pacific Standard Time Zone hours)
• M-F, including occasional evenings or weekends, to align with discharge timing

Core Responsibilities & Expectations for the Role: 

Discharge Planning & Transitions Management 

• 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 

Case Management & Care Coordination 

• 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  

Communication & Documentation 

• 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 

Quality & Compliance 

• 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 

Required Qualifications:   

• 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 

• Remote role (will need to follow Pacific Standard Time Zone hours)

Preferred Qualifications: