Transition of Care Coordinator

Job Summary

Facilitates safe, coordinated transitions of PACE participants between care settings - such as hospital, skilled nursing facilities, PACE centers, home, and other community locations - supporting the interdisciplinary team and promoting independence within the community.

Key Responsibilities

• Coordinate timely and safe transitions from acute care back to home or PACE setting.
• Conduct follow-up calls post-discharge to ensure care plan understanding and adherence.
• Reconcile medications and schedule follow-up appointments after discharge.
• Act as liaison between hospitals, facilities, and the PACE interdisciplinary team (IDT).
• Coach participants and caregivers on self-management and warning sign recognition.
• Participate in IDT meetings to review participant status and plan transitions.
• Document all transitional activities in accordance with PACE standards.
• Track metrics around readmission and quality improvements.

Qualifications

• Associate degree or higher in nursing, social work, or related field.
• 3+ years in care coordination, transitional care, or case management.
• Experience with geriatric and/or Medicare/Medi-Cal populations preferred.
• Strong communication and organizational skills.

Working Conditions

• Reports to PACE Program Coordinator.
• Involves both in-center and home visits, and liaison with post-acute facilities.
• Must comply with all documentation and quality reporting standards.

Impact

• Improves care continuity and reduces hospital readmissions.
• Supports participants and families during care transitions.
• Strengthens participant engagement and overall satisfaction.