Description

You will respond to real-time admission, discharge, or transfer alerts and coordinate seamless transitions across care settings for patients. This field-based role involves conducting home visits, collaborating with hospital staff, and providing care management for up to 90 days post-discharge to prevent readmissions. You'll ensure safe discharges and support patients through critical post-hospitalization periods.

Requirements

• 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

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