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

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.

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…