<p id="isPasted"><strong>Company Overview:</strong></p> <p>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!</p> <p><strong>Job Title & Role Description:</strong></p> <p>The <strong>Transitions of Care Nurse (RN) </strong>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.</p> <p><strong>Key Responsibilities</strong></p> <ul> <li>Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients into Upward Health services.</li> <li>Collaborate with hospital staff, providers, and discharge planners to create safe transition plans.</li> <li>Conduct a home visit within 2 business days of discharge to reconcile medications, confirm follow-up appointments, and assess home safety.</li> <li>Address post-discharge needs, including arranging home health, physical therapy, or durable medical equipment.</li> <li>Provide care management for up to 90 days post-discharge, with a focus on preventing readmissions and supporting patient goals.</li> <li>Educate patients and caregivers on care plans, treatment adherence, and community resources.</li> <li>Document all encounters in the EHR in real time and communicate care updates to the multidisciplinary team.</li> </ul> <p><strong>Skills Required:</strong></p> <ul> <li>Registered nursing license (unrestricted)</li> <li>Experience in hospital-based care coordination, case management, or transitions of care.</li> <li>Strong clinical assessment and critical thinking skills.</li> <li>Ability to perform in-home visits and collaborate across hospital and community settings.</li> <li>Excellent communication and patient education skills.</li> <li>Proficiency with electronic health records and digital care coordination tools.</li> <li>Reliable transportation, valid driver’s license, and auto insurance.</li> <li>Case management certification is a plus but not required</li> </ul> <p style="line-height: 1.2;"><strong>Health Requirements:</strong></p> <p style="line-height: 1.2;">Due to the requirement to visit patients in hospitals, the below screenings and immunizations are required:</p> <ul> <li>Current CDC-recommended Tuberculosis (TB) screening.</li> <li>COVID-19 vaccination, including booster(s).</li> <li>Proof of Hepatitis B vaccination series or signed declination.</li> <li>Proof of MMR (Measles, Mumps, and Rubella) vaccination.</li> <li>Proof of TDAP (Tetanus, Diphtheria, and Pertussis) vaccination.</li> <li>Proof of Varicella (Chickenpox) vaccination.</li> </ul> <p><strong>Competencies:</strong></p> <p>Clinical Expertise: </p> <ul> <li>Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.</li> </ul> <p>Effective Communication: </p> <ul> <li>Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.</li> </ul> <p>Care Plan Development: </p> <ul> <li>Proficient in creating personalized care plans that address physical, behavioral, and social health needs.</li> </ul> <p>Technology Proficiency: </p> <ul> <li>Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.</li> </ul> <p>Outcome-Oriented: </p> <ul> <li>Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.</li> </ul> <p>Independent and Team-Oriented: </p> <ul> <li>Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.</li> </ul> <p>Critical Thinking: </p> <ul> <li>Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.</li> </ul> <p>Multitasking and Prioritization: </p> <ul> <li>Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.</li> </ul> <p>Patient Engagement: </p> <ul> <li>Motivates patients to follow care plans and improve self-care skills through regular communication and support.</li> </ul> <p> </p> <p>Upward Health is proud to be an equal opportunity employer. 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