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Care Transitions Nurse - RN


  • Job Type: Full-Time
  • Function: Life Sciences R&D/Engineering
  • Industry: Healthcare
  • Post Date: 06/23/2022
  • Website:
  • Company Address: Rising Sun Mills, 188 Valley Street, Suite 201, Providence, RI, 02909

About UpwardHealth

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs.

Job Description

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as lengthy delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It is no wonder 98% of patients report being fully satisfied with Upward Health!

Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or you could join us and experience it all for yourself.


The primary responsibility of the Care Transitions Nurse is to ensure the safe and effective transition of care for patients discharging from various sites of care to home – hospital discharges, skilled nursing facility discharges, rehabilitation discharges, etc. Through telephonic-based outreach, the Care Transitions Nurse will contact the patient or caregiver within 48-hours of discharge to conduct a comprehensive discharge assessment, conduct medication reconciliation, provide patient or caregiver education, support post-discharge order fulfillment (i.e., Durable Medical Equipment, Home Health Care, etc.), and assess for any potential barriers to a successful transition to home. Additionally, the Care Transitions Nurse, will confirm the patient has a provider appointment within 7-14 days of discharge, or sooner, depending on the post-discharge needs of the patient. Lastly, the Care Transitions Nurse will identify and coordinate care through available community resources to support closing gaps in identified social needs of the patient.

The Care Transitions Nurse will also serve as the primary daytime triage for patients calling Upward Health with urgent/emergent needs. The goal is to assess and prevent disease exacerbations before the patient needs higher acuity levels of care (i.e., Emergency Department or Hospitalization). Admission prevention is the key to the Care Transitions Nurse and a priority focus of the role. In addition to phone triage, the Care Transitions Nurse will be the first point of contact for patients on Remote Patient Monitoring (RPM) and will immediately assess and triage when specific results are outside of expected ranges – bringing that to the attention of an Upward Health provider or the patient’s own Primary Care Physician (PCP).

Additionally, the Care Transitions Nurse will play a key role in closing patient’s gaps in care through both chart review and telephonic-based call campaigns focused on specific quality care measures. This can include, partnering with Upward Health providers or the patient’s PCP to order necessary tests addressing gaps in care.


  • Monitor daily ADT alerts (ADT: Admit, Discharge, Transfer) for patient outreach and assessment
  • Performs telephonic patient assessment within 48-hours of discharge and provides patient education, support for treatment regimen adherence, and conducts medication reconciliation & management to support self-management and independent living
  • Identifies potential discharge care gaps and communicates through providers as necessary to close gaps in care
  • Direct participation in call campaigns to close identified gaps in care in specific patient populations
  • Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed
  • Notifies Primary Care Provider/staff of any urgent needs or concerns
  • Schedules face-to-face visit with PCP/NP
  • Educate patients and families about treatment plans and options
  • Respond to RPM patient alerts – following Medical Affairs approved protocols
  • Answers inbound patient/caregiver calls and triages per Medical Affairs approved protocols
  • Accurately document and submit medical documentation
  • Maintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomes 
  • Review results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findings
  • Documents all patient encounters in the patient’s electronic medical record
  • Participate with other care team members in regular or special meetings such as Clinical rounds
  • Perform other duties as assigned




  • Interpersonal savvy, with the demonstrated ability to interact with and influence people to establish trust and build strong relationships
  • A high sense of urgency and can-do attitude required for a role at a start-up company
  • Strong organization skills and ability to manage and maintain a personal schedule
  • Ability to establish priorities and meet deadlines
  • Ability to work independently within a virtual operating environment and as part of a team
  • Excellent oral and written communication skills
  • Ability to conduct written and oral instructions
  • Ability to exercise judgment in the application of professional services



  • Unrestricted registered nursing license in the state(s) where nursing care activities are provided – compact registered nursing license for broader state coverage
  • Demonstrated expertise in care transition management and coordination across all healthcare providers, patient, and caregivers
  • Experience with completing real-time documentation in EHR and/or Care Management systems
  • Ability to effectively communicate across a multitude of key care partners
  • Ability to motivate patients and caregivers to follow care plans and optimize self-care potential
  • Excellent documentation skills with the ability to manage multiple patient cases
  • Sound critical thinking skills to assess, analyze and monitor outcomes to recommend the optimal plan of care
  • Computer literacy and ability to effectively communicate within the business structure



  • 3+ years of care transition or care coordination experience
  • 3+ years working in a hospital, health plan or related healthcare business entity also considered
  • Experience serving the Medicare, Medicaid, and Duals population


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. All individuals selected for a position will undergo a background check appropriate for the position's responsibilities.

**We require all our employees to be vaccinated and to show proof of vaccination upon hire**

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