Remote Transitions of Care RN - Discharge & Care Coordination

Upward Health, Inc.; Hayward (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 across California. You will respond to ADT alerts, enroll patients in our services, and coordinate seamless care transitions from hospital to home.

The role includes home visits within 2 business days of discharge, medication reconciliation, and arranging follow-up care. Strong communication, care planning, and EHR documentation are essential to reduce readmissions and support patient goals.

Qualifications

• Unrestricted registered nursing license is required.
• Experience in hospital-based care coordination or transitions of care.
• Strong clinical assessment and critical thinking.
• Ability to perform in-home visits and coordinate with hospital and community settings.
• Excellent communication and patient education skills.
• Proficiency with electronic health records (EHR).
• Reliable transportation and valid driver’s license.

Responsibilities

• Respond to ADT alerts in real time and 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-up care.
• Arrange home health, physical therapy, or durable medical equipment as needed.
• Provide care management for up to 90 days post-discharge to prevent readmissions.
• Educate patients and caregivers on care plans, treatment adherence, and resources.
• Document encounters in the EHR in real time and communicate updates to the team.

Skills

RN license

Care coordination

Clinical assessment

In-home visits

Patient education

Driver's license

Case management cert

Tools

EHR systems

Job description

Upward Health, Inc. is seeking a Transitions of Care Nurse (RN) for field-based work across California. You will respond to ADT alerts, enroll patients in our services, and coordinate seamless care transitions from hospital to home.

The role includes home visits within 2 business days of discharge, medication reconciliation, and arranging follow-up care. Strong communication, care planning, and EHR documentation are essential to reduce readmissions and support patient goals.