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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver’s license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not required
Key Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less
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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver’s license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not required
Key Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less
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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver’s license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not required
Key Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less
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 requiredCompetencies:
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 USDUpward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less
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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver’s license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not required
Key Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less
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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver's license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not requiredKey Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read LessCompany 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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required:
Registered nursing license (unrestricted)Expertise in care management and coordination across healthcare providersStrong communication skills for patient and caregiver educationAbility to conduct both in-home and telephonic assessments, care plans, and medication reconciliationsExperience with EHR systems and real-time documentationAbility to work independently and manage multiple patient casesCritical thinking and decision-making skills in developing care plansProficient in using digital tools for care coordination and communicationA valid driver's license and auto liability insuranceReliable transportation and the ability to travel within assigned territory or as neededCase management certification is a plus but not requiredKey Behaviors:
Patient-Centered Care:
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.Collaboration:
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.Proactive Communication:
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.Advocacy and Education:
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.Care Coordination:
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.Time Management:
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.Problem Solving:
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.Confidentiality:
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.Cultural Competence:
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.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.
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read LessCompany 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 requiredCompetencies:
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 USDUpward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel
Read Less