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Salary: USD 48 - 77 / hourly
Habitat Health is a healthcare company that delivers comprehensive medical and social care to older adults through the Program of All-Inclusive Care for the Elderly (PACE). The company operates care centers and provides in-home services, supported by leading investors including New Enterprise Associates, Kaiser Permanente, and Town Hall Ventures.
The Transitions of Care RN is a centralized, remote clinical operations role 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 and unplanned hospitalizations, skilled nursing facility stays, and emergency department visits—ensuring safe, timely, and well-coordinated returns to the community.
Key Responsibilities:
Discharge Planning & Transitions Management:
- Initiate and manage discharge planning for PACE participants admitted to hospitals, skilled nursing facilities, or emergency departments
- Coordinate with inpatient care teams, interdisciplinary team (IDT) members, and external network providers to facilitate smooth, timely transitions back to home or community settings
- Ensure all post-discharge services—including transportation, durable medical equipment, 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 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:
- Maintain clear, timely communication with all stakeholders (inpatient facilities, IDT members, participants, families, community partners)
- Document all transitions activities, clinical assessments, and coordination efforts in the electronic health record
- Prepare transition summaries and ensure continuity of clinical information
Qualifications:
The posting does not explicitly state required years of experience, education level, or specific certifications. However, the role requires a registered nurse (RN) license and the ability to manage complex care transitions, coordinate across multiple healthcare settings, and work independently in a remote environment. Candidates should have experience with discharge planning, case management, and care coordination in healthcare settings. Knowledge of PACE programs or geriatric care is beneficial. Strong communication, organizational, and problem-solving skills are essential.
