Transitions of Care Nurse

Upward Health•Hayward, CA

5d•Remote

About The Position

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! 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.

Requirements

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.

Nice To Haves

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, 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.