RN - Clinical Transitions Specialist

About the role

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of Carle Health. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. Utilizes the five components of case management: assessment, coordination, monitoring, implementation, and evaluation.

Responsibilities

• Act as a liaison working with patient/family and physician to determine next level of care and manage LOS.
• Coordinates the transition from inpatient care to post-hospital care, collaborating with physicians, consultants, internal and external referrals to facilitate appropriate next level of care to meet patient goals and outcomes.
• Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients.
• Evaluates effectiveness of plan of care and collaborates with physicians to ensure the progression toward desired patient outcomes while managing risk for readmission and length of stay.
• Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider.
• Initiates intervention, both pre-hospital, in-hospital, and post-hospital, for patients and families identified from a proactive initial admission assessment, as well as through referrals from members of the healthcare team.
• Participates in multidisciplinary rounds and initiates timely referrals to other internal healthcare team members (quality improvement, risk manager, social workers, pharmacy, therapy services, etc.).
• Performs case management activities of assessment, coordination, planning, monitoring, implementation, and evaluation.
• Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education.
• Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs.
• Conducts case review presentations to educate peers on unique or challenging cases and scope of practice issues.
• Tracks avoidable days on inpatient stays.
• Performs readmission assessment of inpatient stays.
• Assesses patients for post discharge needs within 24-48 hours of admission and ongoing throughout the stay.
• Assesses patients' risk for readmission and navigates strategies with patient and family to reduce risk through post-acute planning.
• Arranges DME, Home Care, outpatient infusion and coordinates with social work for Hospice, ECF Placement, and Transportation.
• Delivers or delegates delivery of regulatory letters for Medicare and observation patients.
• Arranges/attends any patient/family care conferences.

Requirements

• Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Bachelor's Degree

About Us

At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College.

Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

Pay

The compensation range for this position is $35.87 per hour - $58.37 per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked, and compensation model.

Benefits

Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.