[Hiring] Transitions of Care RN @Habitat Health

Role Description

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.

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 care after transition outcomes.
  • Maintain compliance with state and federal regulations, and Habitat Health policies and procedures.

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.
• Bilingual skills (Spanish or other languages reflective of participant communities).

Preferred Qualifications

• 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.

Compensation

We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for medical/dental/vision insurance, short and long-term disability, life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays. The expected salary range for this position is California Based candidates $62 - $77 per hour; Candidates outside of California, $48 - $53 per hour. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location.

Vaccination Policy, including COVID-19

To help maintain a safe environment for our participants and team members, Habitat Health maintains vaccination and infection control policies applicable to certain roles and work locations. For COVID-19 and influenza, team members who are working in a participant care setting are required to provide either proof of vaccination or a signed declination form and comply with applicable masking requirements while in a care setting to the extent permitted by law in the applicable jurisdiction.

Our Commitment to Equal Opportunity and Inclusion

Habitat Health is an Equal Opportunity Employer committed to the principles of equal opportunity and inclusion. Employment decisions at Habitat Health are based on qualifications, merit, and business needs. We do not discriminate on the basis of race, color, religion, creed, sex, gender (including pregnancy, childbirth, breastfeeding, and related medical conditions), gender identity, gender expression, sexual orientation, marital status, registered domestic partner status, age, national origin, ancestry, citizenship, military or veteran status, physical or mental disability, medical condition, genetic information, reproductive health decision-making, or any other characteristic protected by applicable federal, state, or local law.

E-Verify Participation Notice

Habitat Health participates in E-Verify and will provide the federal government with information from your Form I-9 to confirm your authorization to work in the United States. If E-Verify cannot confirm your authorization to work, Habitat Health will provide you with written instructions and an opportunity to contact the Department of Homeland Security (DHS) and/or the Social Security Administration (SSA) to resolve the issue before any adverse employment action is taken, including termination of employment.

Beware of Scams and Fraud

Habitat Health is committed to protecting job seekers from recruitment scams. Please ensure that you submit applications only through Habitat Health's official careers website or authorized job boards. Official communications from Habitat Health recruiters and team members will come from email addresses ending in @habitathealth.com. Habitat Health will never ask applicants to pay fees, purchase equipment, or provide sensitive financial information as part of the recruiting or hiring process.