Clinical Transition Specialist RN

1 month ago


Urbana, Illinois, United States Carle Health Full time
Job Summary

We are seeking a highly skilled and experienced Clinical Transition Specialist RN to join our team at Carle Health. As a key member of our care coordination team, you will play a critical role in ensuring the seamless transition of patients from acute care to post-acute settings.

Key Responsibilities
  • Act as a liaison between patients, families, and healthcare providers to determine the 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 but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients
  • Evaluate the effectiveness of the plan of care to ensure progression toward desired patient outcomes
  • Initiate interventions, 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 healthcare team
  • Initiate timely referrals to other healthcare 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
  • Readmission assessment of inpatient stays
  • Assess patients for post-discharge needs
  • Participate in daily whiteboard 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 providers before patient discharges, make post-discharge phone calls to ensure patients are doing well and have what they need for success. Obtain prior authorizations for swing bed patients, maintain the work queues, and address denials
  • RMH: make follow-up appointments with primary care providers before patient discharges, make post-discharge phone calls to ensure patients are doing well and have what they need for success. Initial utilization review for emergency room patients being admitted

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:

Effective September 20, 2021, the COVID-19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.



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