Transition of Care RN
Habitat Health · United States · 1 mo ago
RemoteRemoteHealthcare$62–$77/hrFull-time
We need to output HTML fragment with sections: About the role? Actually we need to use for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must not repeat job title as heading. We must include sections only when posting has real specific content. We need to extract content.
The posting includes:
- Intro about Habitat Health (mission). That could be "About the role"? Actually "About the role" is a heading for description of role. Could use "About the role" for role scope description.
- Role Scope paragraph: 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.
That's role description.
- Core Responsibilities & Expectations for the Role: then bullet list under subheadings: Discharge Planning & Transitions Management, Case Management & Care Coordination, Communication & Documentation, Quality & Compliance. Each with bullet points.
We need to output
for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must not repeat job title as heading. We must include sections only when posting has real specific content. We need to extract content.
The posting includes:
- Intro about Habitat Health (mission). That could be "About the role"? Actually "About the role" is a heading for description of role. Could use "About the role" for role scope description.
- Role Scope paragraph: 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.
That's role description.
- Core Responsibilities & Expectations for the Role: then bullet list under subheadings: Discharge Planning & Transitions Management, Case Management & Care Coordination, Communication & Documentation, Quality & Compliance. Each with bullet points.
We need to output - for any list of duties/requirements/benefits. So we can group responsibilities under a
with items.
We also have Required Qualifications and Preferred Qualifications. Those can go under Requirements or Qualifications sections. The instruction says use headings like Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide which sections to include.
We have qualifications: Required Qualifications (list). Preferred Qualifications (list). Could combine under "Qualifications" heading with sub-sections? But we must not create headings not listed? The instruction: "use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It gives examples but not exclusive. Probably we can use those headings. We need to include sections only when posting has real specific content.
We have content for:
- About the role (role scope)
- Responsibilities (core responsibilities)
- Requirements (maybe required qualifications)
- Qualifications (maybe preferred qualifications? Or we could combine required and preferred under Qualifications)
- Skills (maybe from required qualifications: communication, critical thinking, organizational skills, etc.)
- Benefits (compensation paragraph includes benefits list)
- Pay (salary range)
- Schedule (maybe not explicit; they mention ability to work flexible hours, occasional evenings or weekends. That's schedule info. Could include Schedule section.
We must not include sections with filler like "commensurate with experience". We have actual pay range.
We must not include boilerplate like EEO, E-Verify, scam warnings, vaccination policy, etc. Remove those.
We must preserve all substantive information; do not invent or summarize away detail. So we need to keep all details from the posting that are substantive: role scope, responsibilities bullet points, required qualifications, preferred qualifications, benefits list, pay range, schedule note (flexible hours, occasional evenings/weekends). Also maybe mention remote role.
We must not repeat job title as heading. So no heading like "Transitions of Care RN". Already not.
We must not put Job ID/requisition numbers as headings (none present).
We need to output only HTML fragment, no /, no markdown fences.
Let's structure:
About the role
... role scope paragraph ...
Responsibilities
- ... each bullet ...
...
We have four subcategories; we could keep them as separate ? Not allowed? Only h3 for section headings. Could embed subheadings as inside li? But better to keep each responsibility as li items, maybe with internal headings? The instruction: Use - for any list of duties/requirements/benefits. So we can just list each duty as li. Could combine multiple sentences per li.
We need to preserve all details: Under Discharge Planning & Transitions Management: bullet points:
- 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
Now 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
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)
Benefits: from compensation paragraph: medical/dental/vision insurance, short and long-term disability, life insurance, flexible spending accounts, 401(k) savings, paid time off, company-paid holidays.
Pay: expected salary range: California Based candidates $62 - $77 per hour; Candidates outside of California, $48 - $53 per hour.
Schedule: ability to work flexible hours, including occasional evenings or weekends, to align with discharge timing. Already included in qualifications but could be separate schedule section.
We need to avoid duplication. The schedule info appears also in required qualifications. We could still include schedule section with that detail, but we must not repeat content? The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." It doesn't forbid duplication, but better to avoid redundancy. However schedule is a separate section; we could include it and note flexible hours etc. It's okay if it's also in qualifications; but we might choose to not duplicate and instead put schedule info under Schedule heading only, and remove from qualifications? But qualifications list includes that ability; if we remove it, we lose that detail from qualifications. Could keep it in both places? Might be considered duplication but not prohibited. Safer to keep it only under Schedule and remove from qualifications? But then we lose that qualification detail. However the qualification list includes many items; we could keep it there and also have schedule section referencing it? Might be okay.
Given instruction to prefer few substantive sections over many thin ones, maybe we combine schedule into qualifications or responsibilities? But they asked to use headings like Schedule if posting actually states them. The posting does state ability to work flexible hours, occasional evenings or weekends. So we should include Schedule section.
We can keep that detail also in qualifications; it's not harmful.
Now we need to output HTML.
Let's craft:
About the role
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.
Responsibilities
- 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
- 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
- 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
- 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
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 fra
- with items.
We also have Required Qualifications and Preferred Qualifications. Those can go under Requirements or Qualifications sections. The instruction says use headings like Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide which sections to include.
We have qualifications: Required Qualifications (list). Preferred Qualifications (list). Could combine under "Qualifications" heading with sub-sections? But we must not create headings not listed? The instruction: "use
- ... each bullet ... ...
- for any list of duties/requirements/benefits. So we can just list each duty as li. Could combine multiple sentences per li.
We need to preserve all details: Under Discharge Planning & Transitions Management: bullet points:
- 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
Now 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
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)
Benefits: from compensation paragraph: medical/dental/vision insurance, short and long-term disability, life insurance, flexible spending accounts, 401(k) savings, paid time off, company-paid holidays.
Pay: expected salary range: California Based candidates $62 - $77 per hour; Candidates outside of California, $48 - $53 per hour.
Schedule: ability to work flexible hours, including occasional evenings or weekends, to align with discharge timing. Already included in qualifications but could be separate schedule section.
We need to avoid duplication. The schedule info appears also in required qualifications. We could still include schedule section with that detail, but we must not repeat content? The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." It doesn't forbid duplication, but better to avoid redundancy. However schedule is a separate section; we could include it and note flexible hours etc. It's okay if it's also in qualifications; but we might choose to not duplicate and instead put schedule info under Schedule heading only, and remove from qualifications? But qualifications list includes that ability; if we remove it, we lose that detail from qualifications. Could keep it in both places? Might be considered duplication but not prohibited. Safer to keep it only under Schedule and remove from qualifications? But then we lose that qualification detail. However the qualification list includes many items; we could keep it there and also have schedule section referencing it? Might be okay.
Given instruction to prefer few substantive sections over many thin ones, maybe we combine schedule into qualifications or responsibilities? But they asked to use headings like Schedule if posting actually states them. The posting does state ability to work flexible hours, occasional evenings or weekends. So we should include Schedule section.
We can keep that detail also in qualifications; it's not harmful.
Now we need to output HTML.
Let's craft:
About the role
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.
Responsibilities
- 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
- 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
- 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
- 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
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 fra
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It gives examples but not exclusive. Probably we can use those headings. We need to include sections only when posting has real specific content.
We have content for:
- About the role (role scope)
- Responsibilities (core responsibilities)
- Requirements (maybe required qualifications)
- Qualifications (maybe preferred qualifications? Or we could combine required and preferred under Qualifications)
- Skills (maybe from required qualifications: communication, critical thinking, organizational skills, etc.)
- Benefits (compensation paragraph includes benefits list)
- Pay (salary range)
- Schedule (maybe not explicit; they mention ability to work flexible hours, occasional evenings or weekends. That's schedule info. Could include Schedule section.
We must not include sections with filler like "commensurate with experience". We have actual pay range.
We must not include boilerplate like EEO, E-Verify, scam warnings, vaccination policy, etc. Remove those.
We must preserve all substantive information; do not invent or summarize away detail. So we need to keep all details from the posting that are substantive: role scope, responsibilities bullet points, required qualifications, preferred qualifications, benefits list, pay range, schedule note (flexible hours, occasional evenings/weekends). Also maybe mention remote role.
We must not repeat job title as heading. So no heading like "Transitions of Care RN". Already not.
We must not put Job ID/requisition numbers as headings (none present).
We need to output only HTML fragment, no /, no markdown fences.
Let's structure:
About the role
... role scope paragraph ...