Remote Transitions of Care Nurse (RN)

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

Job summary

Upward Health, Inc. is seeking a Transitions of Care Nurse (RN) to coordinate safe hospital admissions, discharges, and transfers. The role includes real-time ADT response, patient engagement during hospitalization, and guiding seamless transitions to home health and follow-up care.

You will support a 90-day post-discharge plan to prevent readmissions and improve outcomes. The position requires an unrestricted RN license, strong assessment and communication skills, and ability to work with

Qualifications

• Active RN license (unrestricted) required.
• 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 (EHR) and care coordination tools.
• Reliable transportation with 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 and confirm follow-ups.
• Address post-discharge needs, including arranging home health, PT, or DME.
• Provide care management for up to 90 days post-discharge to prevent readmissions.
• Educate patients and caregivers on care plans and adherence.

Skills

RN license

Care coordination

Transitions of care

Clinical assessment

In-home visits

Communication skills

EHR proficiency

Driver's license/transportation

Tools

EHR software

Job description

Upward Health, Inc. is seeking a Transitions of Care Nurse (RN) to coordinate safe hospital admissions, discharges, and transfers. The role includes real-time ADT response, patient engagement during hospitalization, and guiding seamless transitions to home health and follow-up care.

You will support a 90-day post-discharge plan to prevent readmissions and improve outcomes. The position requires an unrestricted RN license, strong assessment and communication skills, and ability to work with