Transitions of Care Nurse (RN) Field-Based Role

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

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.