Transitions of Care Nurse

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

Company Overview

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs - everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals - because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description

The Transitions of Care Nurse (RN) is a field-based role focused on patients experiencing an admission, discharge, or transfer (ADT) event. This nurse responds to real-time ADT alerts, engages patients during hospitalization, and coordinates seamless transitions across care settings. The role ensures safe discharges, prevents avoidable readmissions, and supports patients through the critical first 90-day post-discharge.

Key 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, 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 Required

• 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

Health Requirements

• Current CDC-recommended Tuberculosis (TB) screening.


• COVID-19 vaccination, including booster(s).


• Proof of Hepatitis B vaccination series or signed declination.


• Proof of MMR (Measles, Mumps, and Rubella) vaccination.


• Proof of TDAP (Tetanus, Diphtheria, and Pertussis) vaccination.


• Proof of Varicella (Chickenpox) vaccination.

Clinical Expertise

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

Pay Range: $95,000 USD - $105,000 USD