Transition of Care RN

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.
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.
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