In-Home Care Transitions Nurse (RN)

Upward Health; Dublin (CA); On-site; USD 95,000 - 105,000; Full time

Job summary

Upward Health in California seeks a Transitions of Care Nurse (RN) to coordinate care for patients experiencing admissions, discharges, or transfers. You will respond to real-time alerts, engage patients during hospitalization, and orchestrate smooth transitions across care settings.

This field-based role ensures safe discharges, helps prevent readmissions, and supports patients through the crucial first 90 days post-discharge with strong clinical and communication skills.

Qualifications

• Registered nursing license (unrestricted).
• Experience in hospital-based care coordination, case management, or transitions of care.
• Strong clinical assessment and critical thinking skills.
• Ability to perform in-home visits and collaborate across hospital and community settings.
• Excellent communication and patient education skills.
• Proficiency with electronic health records and digital care coordination tools.
• Reliable transportation, valid driver’s license, and auto insurance.
• Case management certification is a plus but not required.

Responsibilities

• Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients into Upward Health services.
• Collaborate with hospital staff, providers, and discharge planners to create safe transition plans.
• Conduct a home visit within 2 business days of discharge to reconcile medications, confirm follow-up appointments, and assess home safety.
• Address post-discharge needs, including arranging home health, physical therapy, or durable medical equipment.
• Provide care management for up to 90 days post-discharge, with a focus on preventing readmissions and supporting patient goals.
• Educate patients and caregivers on care plans, treatment adherence, and community resources.
• Document all encounters in the EHR in real time and communicate care updates to the multidisciplinary team.

Skills

Registered nursing license

Care coordination

Transitions of care

In-home visits

EHR proficiency

Communication skills

Driver's license

Care planning

Tools

EHR systems

Job description

Upward Health in California seeks a Transitions of Care Nurse (RN) to coordinate care for patients experiencing admissions, discharges, or transfers. You will respond to real-time alerts, engage patients during hospitalization, and orchestrate smooth transitions across care settings.

This field-based role ensures safe discharges, helps prevent readmissions, and supports patients through the crucial first 90 days post-discharge with strong clinical and communication skills.