Transitions of Care Nurse

Upward Health, Inc.; San Leandro (CA); Hybrid; USD 95,000 - 105,000; Full time

Job summary

Upward Health is seeking a Transitions of Care Nurse (RN) to operate in the field, coordinating patient care during admissions, discharges, and transfers. The role focuses on ensuring safe discharges, preventing readmissions, and guiding patients through the first 90 days post‑discharge.

The nurse will respond to real‑time ADT alerts, collaborate with hospital teams, and conduct home visits to reconcile medications and arrange necessary services, all while ensuring clear documentation in the EHR.

Qualifications

• Must have a registered nursing license (unrestricted).
• Experience coordinating care in hospital settings or transitions of care required.
• Strong clinical assessment and critical thinking skills essential.
• Ability to perform in‑home visits and coordinate across hospital/community settings.
• Excellent communication and patient education abilities.
• Proficient with electronic health records (EHR) and care management tools.
• Reliable transportation, valid driver's license, and auto insurance.

Responsibilities

• Respond to ADT alerts and deploy to hospital to enroll patients into Upward Health services.
• Collaborate with hospital staff 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.
• Arrange post‑discharge services (home health, PT, DME) as needed.
• Provide care management for up to 90 days post‑discharge to prevent readmissions.
• Educate patients and caregivers on care plans and follow‑ups.
• Document encounters in the EHR in real time and communicate updates to the team.

Skills

Registered nursing license

Hospital‑based care coordination

Case management

Transitions of care

Clinical assessment

Communication with patients

Electronic health records (EHR)

In‑home visits

Transportation and driving

Case management certification (a plus)

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

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.

Competencies

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 personalised care plans that address physical, behavioural, 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, analyse, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization

• Manages multiple patient cases simultaneously while prioritising 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