Remote RN: Transitions of Care & Post‑Discharge Support

The Blue Venture Fund; Hayward (CA); On-site; USD 95,000 - 105,000; Full time

Job summary

Upward Health in California is seeking a Transitions of Care Nurse (RN) to coordinate care across hospital and home settings, focusing on safe discharges and preventing readmissions. This field-based role responds to ADT alerts, conducts home visits within 2 business days, reconciles medications, and arranges post-discharge services while documenting in the EHR.

Ideal candidates have an unrestricted RN license, strong communication, and experience in care transitions; a valid driver's license is

Qualifications

• Active, unrestricted RN license.
• Experience coordinating hospital-based care or transitions.
• Strong clinical assessment and critical thinking.
• Ability to perform in-home visits and coordinate across settings.
• Excellent communication and patient education.
• Proficient with EHR and care management tools.
• Valid driver's license and reliable transportation.
• Care management certification is a plus but not required.

Responsibilities

• Respond to ADT alerts in real time and enroll patients in Upward Health services.
• Collaborate with hospital staff to create safe transition plans.
• Conduct a home visit within 2 business days of discharge.
• Arrange home health, physical therapy, or medical equipment as needed.
• Provide care management for up to 90 days post-discharge.
• Educate patients and caregivers on care plans and follow-up.
• Document encounters in the EHR and share updates with the team.

Skills

Hospital-based care coordination

Care management

Clinical assessment

Communication skills

Patient education

EHR proficiency

Driver's license

Team collaboration

Education

RN license (unrestricted)

Tools

EHR

Care management systems

Job description

Upward Health in California is seeking a Transitions of Care Nurse (RN) to coordinate care across hospital and home settings, focusing on safe discharges and preventing readmissions. This field-based role responds to ADT alerts, conducts home visits within 2 business days, reconciles medications, and arranges post-discharge services while documenting in the EHR.

Ideal candidates have an unrestricted RN license, strong communication, and experience in care transitions; a valid driver's license is