Upwardhealth
Transitions of Care Nurse
Alameda, California . Posted 7 months ago
The role
The Transitions of Care Nurse responds to real-time ADT alerts to enroll patients and coordinate transitions across care settings. This field-based role focuses on ensuring safe discharges and preventing avoidable readmissions through home visits and care management.
What you will do
- Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients
- 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
- 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
Required qualifications
- 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
- 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
Nice to have
- Case management certification is a plus but not required
About the company
Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. The clinical team treats physical, behavioral, and social health needs.