Clinical Transition Specialist RN

Overview

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. 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. Multidisciplinary Rounds are completed daily with the care team at the patient's bedside which assists the team for timely planning and collaboration.
Qualifications

Certifications:

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Illinois Department of Financial and Professional Regulation (IDFPR);
Accredited Case Manager (ACM) within 3 years - American Case Management Association (ACMA)
American Case Management Association (ACMA);
Basic Life Support (BLS) within 30 days - American Heart Association (AHA)
American Heart Association (AHA),

Education:

College Diploma:
Nursing (Required),

Work Experience:

None

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. 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. Find it all at Carle Health.

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 Bro Menn 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.

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