Transition of Care RN

Habitat Health; California (MO); On-site; USD 8,541,000 - 10,608,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Short-term disability

Long-term disability

Life insurance

Flexible spending accounts

401(k) savings

Paid time off

Company-paid holidays

Job summary

Habitat Health is seeking a Transitions of Care RN to work remotely within the Clinical Operations team. You will manage discharge planning for PACE participants across hospitals, SNFs, and EDs, coordinating with inpatient teams to ensure safe, timely home returns.

You will monitor patients post-discharge, address SDOH barriers, and keep care plans updated with the IDT. Strong EHR skills and flexible PST hours are required.

Qualifications

• Active RN licensure in California (or compact with CA authorization).
• 2–3 years of clinical nursing experience, with at least 1 year in case management or transitions of care.
• Experience with complex, medically frail older adults.
• Strong knowledge of acute and post-acute care, and community resources.
• Proficiency with electronic health record systems.
• Excellent communication, critical thinking, and organizational skills.
• Ability to work independently in a remote, fast-paced environment.
• Ability to work flexible hours including evenings/weekends.
• Remote role with Pacific Standard Time hours.

Responsibilities

• Initiate and manage discharge planning for PACE participants admitted to hospitals, SNFs, or EDs.
• Coordinate with inpatient teams, IDT members, and external providers for smooth transitions home.
• Ensure post-discharge services (transportation, DME, home health, meds, follow-ups) are arranged before discharge.
• Monitor participants post-discharge via proactive outreach and follow-ups.
• Identify and address social determinants of health to prevent readmissions.
• Collaborate with IDT to update care plans and communicate changes.
• Transition care back to the empaneled IDT after discharge.
• Serve as primary contact between inpatient facilities and IDT during transitions.
• Document transition activities accurately in the EHR.
• Provide health coaching on discharge plan to participants/caregivers.
• Participate in IDT meetings and readmission reviews.

Skills

RN licensure

Nursing experience

Case management

Geriatric care

EHR proficiency

Communication skills

Remote work

Flexible scheduling

PST hours alignment

Education

CCM Certification

Tools

EPIC

Job description

Habitat Health empowers older adults to experiencemore gooddays 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, andin ‑ homeassistance. 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, ourmission ‑ drivencare 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.

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 trans itions — including acute/unp lanned 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:

• 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:

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

Compensation:

We take into account an individual’s qualifications, skill set, 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 hou r. 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, skill set, and geographic location.

To helpmaintaina safe environment for our participants and team members, Habitat Healthmaintainsvaccination 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.

Habitat Health will consider requests for reasonable accommodation based on an applicant's disability, medical condition, orsincerely heldreligious belief, practice, or observancein accordance withapplicable law.

As a condition of employment, team members are expected to comply with all applicable infection control protocols, personal protective equipment (PPE) requirements, and vaccination requirements associated with their role and work location, and to the extent required by law and as permitted in the applicable jurisdiction.

Our Commitment to Equal Opportunity and Inclusion

Habitat Health is an Equal Opportunity Employer committed tothe 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.

Habitat Health is committed to the full inclusion of all qualified individuals. Consistent with applicable law, we provide reasonable accommodations to qualified individuals with disabilities and to individuals with religious beliefs, practices, or observances that require accommodation.

If you require a reasonableaccommodation toparticipatein the application or interview process, perform the essential functions of a position, or receive other employment benefits and privileges, please contact us at [e-mail] .

Habitat Healthparticipatesin 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.

Habitat Health will consider requests for reasonable accommodation based on an applicant's disability, medical condition, or sincerely held religious belief, practice, or observance in accordance with applicable law.

Habitat Health will consider requests for reasonable accommodation based on an applicant's disability, medical condition, or sincerely held religious belief, practice, or observance in accordance with applicable law.

Habitat Healthwill comply with all federal and state employment eligibility verification requirements.

Habitat Healthwill comply with all federal and state employment eligibility verification requirements.