Transitions Of Care Nurse

Upward Health

Alameda County, California, United States
Base: $95,000—$105,000 usd; bonus/equity: not spec...
On-site
Respond to adt alerts in real time
Conduct in-home visits post-discharge
Collaborate with hospital and community providers
Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care addressing physical, behavioral, and social health needs

Job Summary

  • Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care addressing physical, behavioral, and social health needs.
  • The Transitions of Care Nurse responds to real-time ADT alerts, engages patients during hospitalization, and coordinates seamless transitions across care settings to prevent readmissions.
  • Upward Health is proud to be an equal opportunity employer committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce.

Matching Summary

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care addressing physical, behavioral, and social health needs.

Salary

Base: $95,000—$105,000 USD; Bonus/Equity: Not specified; Benefits: Not specified

Skills & Requirements

Must-have

  • Respond to ADT alerts in real time
  • Conduct in-home visits post-discharge
  • Collaborate with hospital and community providers
  • Use electronic health records and care management tools
  • Provide care management up to 90 days post-discharge
  • Excellent communication and patient education skills
  • Reliable transportation and valid driver’s license

Nice-to-have

  • Case management certification
  • Strong clinical assessment and critical thinking
  • Ability to work independently and in teams
  • Outcome-oriented care coordination
  • Motivate patient engagement and self-care
  • Proficient in care plan development
  • Experience with multidisciplinary teams

Key Requirements

  • Registered nursing license (unrestricted)
  • Experience in hospital-based care coordination or case management
  • Reliable transportation with valid driver’s license and auto insurance

Work Rights

Not specified

Tailored Resume

Cover Letter