Transitions of Care Nurse

What this role involves

The Transitions of Care Nurse (RN) is a field-based role focusing on patients during hospital admission, discharge, or transfer. The nurse responds to real-time ADT alerts, collaborates with hospital staff, conducts home visits post-discharge, and provides care management for up to 90 days to prevent readmissions.

Skills this posting asks for

• registered nursing license
• hospital-based care coordination
• case management
• transitions of care
• clinical assessment
• critical thinking
• in-home visits
• collaboration
• communication
• patient education
• electronic health records
• digital care coordination tools
• reliable transportation
• valid driver's license
• auto insurance

Requirements

• Remote policy: onsite

From the employer’s posting

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…