Clinical Transition Specialist RN

Act as a liaison working with patient/family and physician to determine next level of care

Conducts case review presentations to educate peers on unique or challenging cases and scope of practice issues.

Coordinates the transition from inpatient care to post-hospital care, working with pre- and post- hospital providers to ensure responsive and appropriate care is provided post-discharge.

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 to ensure the progression toward desired patient outcomes.

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 health care team.

Initiates timely referrals to other health care team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)

Performs nursing 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.

Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider.

Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs.

Lead an interdisciplinary team to achieve organizational goals related to length of stay and readmissions.

Track avoidable days on inpatient stays.

Readmission assessment of inpatient stays.

Assess patients for post discharge needs.

Participate in daily white board rounds.

Arrange DME, Home Care, Hospice, Extended Care Facilities / Skilled Nursing Facilities, and Transportation

Assist any patient/family care conferences.

Participate in department work groups.

HRHC: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success. Obtain prior authorizations for swing bed patients, maintain the work ques, and address denials.

RMH: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success.

Find it here.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. 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. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.