Transition of Care Coordinator
High Desert Pace IncVictorville, CA, USjob_description.job_card.variable_days_ago
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job_description.job_card.job_descriptionAssociate 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. 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. Improves care continuity and reduces hospital readmissions. Supports participants and families during care transitions. Strengthens participant engagement and overall satisfaction.
Job Description
Job Description
Description : 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.
Requirements : 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
Working Conditions
Impact
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Care Coordinator • Victorville, CA, US