Clinical Transition Specialist RN
3 weeks ago
- 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, assisting with returns to ECFs, 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. Initial utilization review for emergency room patients being admitted.
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Clinical Transition Specialist RN ED
3 days ago
Urbana, Illinois, United States Carle Foundation Hospital Full timeJob Title: Clinical Transition Specialist RN EDCarle Foundation Hospital is seeking a skilled Clinical Transition Specialist RN ED to join our team. As a Clinical Transition Specialist RN ED, you will play a vital role in ensuring the smooth transition of patients from the Emergency Department to other care settings.Key Responsibilities:Conduct comprehensive...
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Clinical Transition Specialist RN ED
5 days ago
Urbana, Illinois, United States Carle Foundation Hospital Full timeJob Title: Clinical Transition Specialist RN EDCarle Foundation Hospital is seeking a skilled Clinical Transition Specialist RN ED to join our team. As a key member of our healthcare team, you will play a vital role in ensuring the seamless transition of patients from the Emergency Department to other care settings.Job Summary:The Clinical Transition...
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Clinical Transition Specialist RN
3 days ago
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Clinical Transition Specialist RN ED
3 days ago
Urbana, Illinois, United States Carle Health Full timeJob SummaryWe are seeking a skilled Clinical Transition Specialist RN ED to join our team at Carle Health. This role will play a critical part in ensuring the seamless transition of patients from the Emergency Department to other care settings.Key ResponsibilitiesConduct comprehensive patient assessments and admission reviews to determine the appropriateness...
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