Transitions of Care Nurse

Upward Health · Alameda, CA · 1 mo ago

HybridHealthcare$95k/yrFull-time

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.

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

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.

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