Remote Transitions Nurse (RN) - Discharge & Home Visits

Upward Health, Inc.; Castro Valley (CA); Remote; USD 95,000 - 105,000; Full time

Job summary

Upward Health, Inc. is seeking a Transitions of Care Nurse (RN) for field-based work focusing on patients during ADT events. You will respond to real-time alerts, enroll patients into Upward Health services, and coordinate safe transitions from hospital to home.

You will conduct home visits within 2 business days of discharge to reconcile medications, arrange follow-up care, and assess home safety, while documenting all encounters in the EHR and coordinating with the care team.

Qualifications

• Registered nurse 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, focusing 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

RN license

Care coordination

Critical thinking

In-home visits

Patient education

EHR proficiency

Driver’s license

Case management cert (plus)

Tools

Care management systems

Job description

Upward Health, Inc. is seeking a Transitions of Care Nurse (RN) for field-based work focusing on patients during ADT events. You will respond to real-time alerts, enroll patients into Upward Health services, and coordinate safe transitions from hospital to home.

You will conduct home visits within 2 business days of discharge to reconcile medications, arrange follow-up care, and assess home safety, while documenting all encounters in the EHR and coordinating with the care team.