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 Practitioner (NP) is responsible for providing high-quality, patient-centered, comprehensive primary care. Utilizing Upward Health’s proprietary Facilitated Virtual Care platform, the NP delivers care that improves outcomes and reduces costs for patients with complex diagnoses and co-morbid, chronic conditions. This role primarily involves virtual patient care with periodic or as needed in-person care to support transitions of care, annual wellness visits, risk adjustments, primary care needs, and urgent visits. The NP collaborates closely with a multidisciplinary team to provide whole-person care to our patients in their homes.

Key Responsibilities:

• Triage, diagnose, and treat patients in person or via our virtual care platform.
• Serve as a day-to-day clinical leader, providing decision support and directing the multidisciplinary team under the guidance of the Medical Director.
• Conduct primary care, urgent visits, and annual wellness exams, ensuring all appropriate screening tests and quality measures are addressed.
• Refer patients appropriately for behavioral health and specialty services.
• Coordinate care transitions to prevent hospital readmissions by collaborating with PCPs, hospitalists, and SNF providers.
• Participate in the on-call provider schedule to support the 24/7 patient hotline, requiring after-hours and weekend availability on a rotating and recurring basis.
• Foster a collaborative working environment with all members of the interdisciplinary team, contributing to daily huddles, team meetings, and patient discussions.
• Monitor and respond to remote patient data collected through monitoring devices.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Perform and document accurate and thorough risk assessments for the purpose of accurate documentation of condition(s).
• Expertise in managing complex, polychronic patients, with demonstrated ability to assess and treat high-acuity patients.
• Familiarity with caring for Medicare and Medicaid populations, with experience in both inpatient and outpatient or home care settings.
• Proficiency in motivational interviewing, trauma-informed care, and supporting vulnerable populations is preferred.
• Excellent written, computer, and oral communication skills, with the ability to communicate efficiently and proactively with the clinical team.
• Dedication to health equity and transforming care for patients in their homes.
• Strong organizational skills and ability to provide clinical leadership and coordination.

Qualifications:

• Minimum of 5 years’ experience as a provider, with a minimum of 3 years in a primary care, or related, setting.
• Multi-state Advanced Nursing License or willingness to obtain.
• A valid driver’s license and auto liability insurance.
• Willingness and ability to travel as needed, though responsibilities are primarily performed virtually.
• Experience in urgent/emergent care settings is a plus.

Key Competencies:

Clinical Leadership:

• Ability to provide decision support and leadership to the care team.

Patient-Centered Care: 

• Focused on delivering high-quality, compassionate care to improve patient outcomes.

Collaboration: 

• Works effectively within a multidisciplinary team to provide comprehensive care

Adaptability: 

• Thrives in a dynamic, fast-paced environment with evolving protocols.

Problem-Solving: 

• Proactively identifies and addresses challenges in patient care and team coordination.

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.

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

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.

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

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.