Upward Health
Transitions of Care Nurse
Alameda, California
Sponsorship not specified$95k-$105kDetected 14 days ago
EHR/EMRCommunicationCritical Thinking
About the role
- 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.
Responsibilities
- Collaborate with hospital staff, providers, and discharge planners to create safe transition plans.
- Document all encounters in the EHR in real time and communicate care updates to the multidisciplinary team.
- Ability to perform in-home visits and collaborate across hospital and community settings.
- Motivates patients to follow care plans and improve self-care skills through regular communication and support.
Requirements
- Due to the requirement to visit patients in hospitals, the below screenings and immunizations are required:
- Clinical Expertise:
- Technology Proficiency:
Skills
- Registered nursing license (unrestricted)
- Experience in hospital-based care coordination, case management, or transitions of care.
- Strong clinical assessment and critical thinking skills.
- 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
Compensation
- California pay range
Benefits
- Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.
- It's no wonder 98% of patients report being fully satisfied with Upward Health!
- Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients into Upward Health services.
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This listing is sourced directly from Upward Health's careers page and normalized into a canonical job model.