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Upward Health · 1 month ago

Transitions of Care Nurse

Oakland, California

Full-time

Onsite

Mid Level

$95K/yr - $105K/yr

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. The Transitions of Care Nurse is responsible for ensuring safe transitions for patients during admission, discharge, or transfer events, focusing on preventing readmissions and supporting patients in their post-discharge journey.

Health CareMedicalService Industry

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

Qualification

Registered nursing licenseHospital-based care coordinationClinical assessment skillsElectronic health recordsCase management certificationPatient education skillsCare plan developmentTechnology proficiencyMultitaskingPrioritizationPatient engagementCommunication skillsCritical thinking

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

Preferred

Case management certification is a plus but not required

Company

Upward Health

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs.

Founded in 2017

Hauppauge, New York, USA

501-1000 employees

https://upwardhealth.com/

Funding

Current Stage

Late Stage

Total Funding

$28.75M

Key Investors

Trinity CapitalHeritage GroupNoro-Moseley Partners

2025-01-16Series C

2025-01-16Debt Financing· $20M

2022-09-13Series B

Leadership Team

Benjamin Hamawy

Chief Financial Officer

Recent News

Business Wire

Upward Health Ranks No. 4 on the 2025 Inc. 5000 List

2025-08-13

PR Newswire

Trinity Capital Inc. Provides $12.5 Million in Growth Capital to Upward Health

2025-01-16

Seeking Alpha

Trinity Capital provides $12.5M in growth capital to Upward Health

2025-01-16

Company data provided by crunchbase