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Transitions Of Care Jobs (NOW HIRING)

Upward Health

Transitions of Care Nurse

Alameda, CA · On-site

$95K - $105K/yr

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 ...

Upward Health

Transitions of Care Nurse

Alameda, CA

$95K - $105K/yr

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 ...

Bayhealth

Transitions of Care Pharmacist

Dover, DE · On-site

The Transitions of Care (TOC) Clinical Pharmacist plays a critical role in supporting the safe, effective, and seamless movement of patients across care settings from the hospital stay to being ...

Bayhealth

Transitions of Care Pharmacist

Milford, DE · On-site

The Transitions of Care (TOC) Clinical Pharmacist plays a critical role in supporting the safe, effective, and seamless movement of patients across care settings from the hospital stay to being ...

CHPW

Transitions of Care Manager, Jail

Seattle, WA · On-site

$35.92 - $55.67/hr

The Licensed Carceral Transitions of Care Manager (CT CM) is responsible for pre-release planning and short-term case management of members releasing from city and county jails, Department of ...

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Transitions Of Care information

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$31.5K

$52.9K

$93K

How much do transitions of care jobs pay per year?

As of Jul 30, 2026, the average yearly pay for transitions of care in the United States is $52,874.00, according to ZipRecruiter salary data. Most workers in this role earn between $40,000.00 and $64,500.00 per year, depending on experience, location, and employer.

What is the difference between Transitions Of Care vs Registered Nurse?

AspectTransitions Of CareRegistered Nurse
CertificationsCPR, ACLS, care coordination certificationsRN license, BLS, ACLS
Work EnvironmentHospitals, clinics, post-acute care settingsHospitals, clinics, community health
Employer & IndustryHealthcare providers, insurance companies, post-acute facilitiesHospitals, clinics, long-term care facilities
Primary FocusCare transitions, patient advocacy, care coordinationPatient care, treatment, health monitoring

Transitions Of Care specialists focus on coordinating patient care during transfers between settings, ensuring smooth transitions and reducing readmissions. Registered Nurses provide direct patient care, monitor health status, and administer treatments. While both roles work within healthcare settings, Transitions Of Care roles emphasize care coordination and communication, whereas Registered Nurses focus on clinical patient care.

More about Transitions Of Care jobs
What cities are hiring for Transitions Of Care jobs? Cities with the most Transitions Of Care job openings:
What states have the most Transitions Of Care jobs? States with the most job openings for Transitions Of Care jobs include:
What job categories do people searching Transitions Of Care jobs look for? The top searched job categories for Transitions Of Care jobs are:
Transitions Of Care jobs near you
Infographic showing various Transitions Of Care job openings in the United States as of July 2026, with employment types broken down into 2% As Needed, 69% Full Time, 21% Part Time, and 8% Contract. Highlights an 94% Physical, 1% Hybrid, and 5% Remote job distribution, with an average salary of $52,874 per year, or $25.4 per hour.

Transitions of Care Nurse

Upward Health

Alameda, CA • On-site

$95K - $105K/yr

Full-time

Re-posted 5 days ago

Job description

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 required

Health Requirements:
Due to the requirement to visit patients in hospitals, the below screenings and immunizations are required:
  • Current CDC-recommended Tuberculosis (TB) screening.
  • COVID-19 vaccination, including booster(s).
  • Proof of Hepatitis B vaccination series or signed declination.
  • Proof of MMR (Measles, Mumps, and Rubella) vaccination.
  • Proof of TDAP (Tetanus, Diphtheria, and Pertussis) vaccination.
  • Proof of Varicella (Chickenpox) vaccination.

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.
California pay range
$95,000-$105,000 USD
Upward Health Benefits
Upward Health Core Values
Upward Health YouTube Channel

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