Transitions of Care Nurse
Company: Upward Health
Location: Oakland
Posted on: January 18, 2026
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Job Description:
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. California pay range
$95,000 - $105,000 USD Upward Health Benefits Upward Health Core
Values Upward Health YouTube Channel
Keywords: Upward Health, North Highlands , Transitions of Care Nurse, Healthcare , Oakland, California
