Remote Transitions of Care Nurse – Post-Discharge Care

Upward Health; Milpitas (CA); Remote; USD 95,000 - 105,000; Full time

Benefits offered by this job

Health benefits

Job summary

Upward Health in Milpitas, CA seeks a Transitions of Care Nurse (RN) to coordinate care for patients during admission, discharge, or transfer events. This field-based role responds to real-time ADT alerts, engages patients during hospitalization, and ensures safe transitions across care settings.

The position supports safe discharges, prevents readmissions, and assists patients through the first 90 days post-discharge. An unrestricted RN license and in-home care experience are required.

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 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

RN license

Care coordination

Clinical assessment

In-home visits

Communication skills

EHR proficiency

Driver's license

Case management certification

Tools

Auto insurance

Job description

Upward Health in Milpitas, CA seeks a Transitions of Care Nurse (RN) to coordinate care for patients during admission, discharge, or transfer events. This field-based role responds to real-time ADT alerts, engages patients during hospitalization, and ensures safe transitions across care settings.

The position supports safe discharges, prevents readmissions, and assists patients through the first 90 days post-discharge. An unrestricted RN license and in-home care experience are required.