Transitions of Care Nurse

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: 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. 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—$105,000 USD Upward Health Benefits Upward Health Core Values Upward Health YouTube Channel