Transitions of Care Nurse

Transitions of Care Nurse

Alameda, California

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

Due to the requirement to visit patients in hospitals, the below screenings and immunizations are required:

• 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 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.