Clinical Care Transition Specialist RN

2 weeks ago

Urbana, Illinois, United States Carle Health Full time


Position Overview:

Accountable for the supervision, coordination, and management of both functional and financial outcomes during acute medical conditions necessitating hospitalization for patients at Carle Health. Ensures that patients undergo a proactive initial assessment of their needs, continuous evaluations, and the initiation of discharge planning, all while facilitating a secure and timely transition from the hospital setting to an appropriate level of care beyond the hospital. Employs the five essential components of case management: assessment, coordination, monitoring, implementation, and evaluation. Engages in daily Multidisciplinary Rounds with the care team at the patient's bedside to enhance timely planning and collaboration.

Qualifications:

EDUCATIONAL REQUIREMENTS
Associate's Degree in Nursing is required, with a Bachelor's Degree in Nursing to be obtained within five (5) years of the start date.

CERTIFICATION & LICENSURE REQUIREMENTS
Must possess a Registered Professional Nurse (RN) License in Illinois upon hire and obtain Accredited Case Manager Certification within three years.

EXPERIENCE REQUIREMENTS
Minimum of three (3) years in a related field.

ADDITIONAL REQUIREMENTS

  • Completion of all required continuing education related to the care of acute stroke patients.
SKILLS AND KNOWLEDGE
Ability to cultivate professional relationships with all healthcare providers, work autonomously and collaboratively, possess strong communication and organizational skills, and demonstrate attention to detail while managing multiple patient cases concurrently.

Key Responsibilities:

  • Serve as a liaison between patients/families and physicians to determine the next level of care.
  • Conduct case review presentations to inform peers about unique or challenging cases and scope of practice issues.
  • Facilitate the transition from inpatient care to post-hospital care, collaborating with pre- and post-hospital providers to ensure appropriate care is delivered after discharge.
  • Document plans of care and utilization issues in relevant systems, including case management/utilization review software and multidisciplinary care plans for all assigned patients.
  • Assess the effectiveness of care plans to ensure progress toward desired patient outcomes.
  • Initiate interventions for patients and families identified through proactive admission assessments and referrals from healthcare team members.
  • Make timely referrals to other healthcare team members, including quality improvement, risk management, social workers, and physicians.
  • Perform nursing activities encompassing assessment, coordination, planning, monitoring, implementation, and evaluation. Engage with clients, caregivers, and families to assess, plan care, arrange services, monitor, and provide support and education.
  • Investigate coverage for post-hospital needs proactively and present options to patients/families and providers.
  • Oversee the acute care plan to ensure coordination and completion of services to meet post-hospitalization needs.
  • Lead an interdisciplinary team to achieve organizational objectives related to length of stay and readmissions.
  • Monitor avoidable days during inpatient stays.
  • Conduct readmission assessments for inpatient stays.
  • Evaluate patients for post-discharge needs.
  • Participate in daily whiteboard rounds.
  • Coordinate Durable Medical Equipment (DME), Home Care, Hospice, and assist with transitions back to Extended Care Facilities (ECFs) and transportation.
  • Support patient/family care conferences.
  • Engage in departmental work groups.
  • Ensure follow-up appointments with primary care providers are scheduled before patient discharge and conduct post-discharge calls to confirm patient well-being and needs for success.
  • Perform initial utilization reviews for emergency room patients being admitted.

Carle Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment based on race, color, sex, age, national origin, religion, sexual orientation, gender identity, veteran status, disability, or any other 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.

Effective September 20, 2021, the COVID-19 vaccine is required for all new Carle Health team members, with requests for medical or religious exemptions permitted.

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