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Transitional Care Jobs in California (NOW HIRING)

Interface Rehab

SLP - Transitional Care

Victorville, CA · On-site

$40.75 - $55/hr

In a Transitional Care setting, the therapist will manage a treatment plan to promote a positive outcome for patients with diverse diagnoses. One year of recent experience in this setting is ...

Interface Rehab

PT - Transitional Care

Victorville, CA · On-site

$1.7K - $2.2K/wk

Travel Physical Therapist Opportunity Prime HealthCare Staffing, a national health care staffing company with over 20 years in the business, is looking for an experienced Physical Therapist for a ...

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Transitional Care information

What is transitional care?

Transitional care refers to a set of coordinated healthcare services that help patients move smoothly from one care setting to another, such as from a hospital to their home or a rehabilitation facility. The goal is to ensure continuity of care and prevent complications, such as hospital readmissions. Transitional care typically involves communication among healthcare providers, medication management, follow-up appointments, and patient education. It is especially important for individuals with complex or chronic conditions who are at higher risk during care transitions.

What are the key skills and qualifications needed to thrive in transitional care?

To excel in Transitional Care, professionals typically require a background in nursing, social work, or case management, along with knowledge of care coordination and discharge planning. Familiarity with electronic health records (EHRs), care management software, and possibly certification like CCM (Certified Case Manager) is often beneficial. Strong communication, empathy, and problem-solving abilities are crucial for effectively supporting patients and collaborating with healthcare teams. These skills ensure smooth care transitions, prevent hospital readmissions, and enhance patient outcomes during vulnerable periods.

How does a transitional care professional typically collaborate with other healthcare teams to ensure smooth patient transitions?

Transitional Care professionals work closely with physicians, nurses, social workers, and other allied health staff to coordinate patient care as individuals move between different healthcare settings, such as from hospital to home. This collaboration often involves regular interdisciplinary meetings, thorough documentation, and clear communication to ensure continuity of care and reduce readmission risks. Effective teamwork is essential, as Transitional Care professionals often serve as liaisons, advocating for patient needs and ensuring all members are updated on care plans. Building strong relationships across departments is a key part of the role, helping to identify and resolve potential barriers to successful transitions.

How to become a transitional care coordinator?

To become a transitional care coordinator, candidates typically need a nursing or healthcare-related degree such as a registered nurse (RN) or social worker license, along with experience in patient care and care coordination. Certification in care management or case management, like the Certified Case Manager (CCM), can enhance job prospects. Strong communication, organizational skills, and knowledge of healthcare systems are essential for success in this role.

What are the most commonly searched types of Transitional Care jobs in California?

The most popular types of Transitional Care jobs in California are:

What cities in California are hiring for Transitional Care jobs?

Cities in California with the most Transitional Care job openings:

Transitional Care jobs near you
Infographic showing various Transitional Care job openings in California as of August 2026, with employment types broken down into 2% As Needed, 74% Full Time, 18% Part Time, and 6% Contract. Highlights an 93% Physical, 1% Hybrid, and 6% Remote job distribution.

Registered Nurse - Transitional Care (FULL TIME)

Global Transitional Care

San Diego, CA

Full-time

Re-posted 13 days ago

Job description

Company Description

Global Transitional Care (GTC) is the first third-party specialty group provider organization dedicated to providing comprehensive transitional care. Our mission is to enhance the care continuum and provide personalized clinical oversight for each individual patient.

GTC helps avoid complications and readmission to the hospital by helping to manage all aspects of care from inpatient stay to home for 30 days from date of discharge. Through a transitional care provider team, patients and their families will have access to a healthcare provider that is familiar to them and their case, 24 hours a day, 7 days a week.

GTC's goal in transitional care is to give the newly discharged patient and their healthcare team continuity of medical and post discharge care, further reducing adverse events, unnecessary return visits to the hospital or emergency room, and the knowledge to personally manage their own health condition.

Job Description

Under the supervision of an Advanced Practice Transitional Care Nurse (AP-TCN), the Transitional Care Nurse provides continuity of care throughout a patient's episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the TCN coordinates and implements the individualized plan of care. TCNs use their clinical judgment to determine the 'discharge readiness' of each patient. The Transitional Care Nurse also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.


Major Responsibilities:

Conducts face-to-face visits with patient in healthcare facilities and in patients' homes

Initiates telephone outreach and is available by phone during office and on-call hours 

Works independently and keeps physicians informed of patient status.

Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients' needs.

Provides health maintenance, and medication and disease management education to patients and families/caregivers

Collects, organizes, documents, and analyzes data, synthesizing it into understandable information

Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient's primary healthcare provider(s) and AP-TCN

Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing

Works with outside facilities and agencies on a routine basis, maintaining positive working relationships

Supports patients and their families, and provides compassionate care

Reports back to supervising AP-TCN and Director of Nursing

Qualifications

Authorization to work in the US

Associates Degree from an accredited Nursing Program

Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license

BLS

Car, driver's license, auto insurance and safe driving history

English proficiency, bilingual a plus

Computer literacy (i.e. Microsoft Office Suite)

Must have a cell phone, computer, internet, and email access  


Preferred Qualifications:

BSN

Public Health and/or Case Management certification

Community Education Experience

Additional Information

All your information will be kept confidential according to EEO guidelines.

Apply