Clinical Transition Specialist RN Weekend - CFH

Overview

$5,000 sign on bonus for external candidates with 1 year of nursing experience

$2,500 relocation bonus for over 50 miles OR $5,000 for over 100 miles

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.

• Accredited Case Manager (ACM) within 3 years – American Case Management Association (ACMA)
• Basic Life Support (BLS) within 30 days – American Heart Association (AHA)
• Licensed Registered Professional Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR)
• College Diploma in Nursing
• Work experience in case management (details not specified)

• Act as liaison working with patient/family and physician to determine next level of care
• Conduct case review presentations to educate peers on unique or challenging cases and scope of practice issues
• Coordinate 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
• Document plan of care and utilization issues in appropriate locations, including case management/utilization review software and the multidisciplinary plan of care document for all assigned patients
• Evaluate effectiveness of plan of care to ensure progression toward desired patient outcomes
• Initiate 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
• Initiate timely referrals to other health care team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)
• Perform nursing activities of assessment, coordination, planning, monitoring, implementation, and evaluation; interact with clients, caregivers, and families to assess, plan care, arrange services, monitor, and provide support and education
• Proactively investigate coverage for post‑hospital needs and present options to the patient/family and provider
• Provide 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 and readmission assessment of inpatient stays; assess patients for post‑discharge needs
• Participate in daily white board rounds; arrange DME, Home Care, Hospice, assisting with returns to ECFs, and Transportation; attend any patient/family care conferences
• Participate in department work groups; schedule follow‑up appointments with primary care provider before patient discharges; make 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 queue, and address denials
• Initial utilization review for emergency room patients being admitted

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.

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…