Clinical Care Transition Specialist RN

2 weeks ago

Urbana, Illinois, United States Carle Health Full time


Position Overview:

The Clinical Care Transition Specialist RN is accountable for overseeing, coordinating, and managing both the functional and financial outcomes during periods of acute illness that necessitate hospitalization for patients at Carle Health. This role is essential in ensuring that patients undergo a proactive initial assessment of their needs, receive ongoing evaluations, and that discharge planning is initiated effectively, facilitating a safe and timely transition from the hospital to an appropriate level of care outside the acute setting.

Key Responsibilities:

Utilizing the five core components of case management—assessment, coordination, monitoring, implementation, and evaluation—this position involves:

  • Conducting daily multidisciplinary rounds at the patient's bedside to promote timely planning and collaboration among the care team.
  • Acting as a liaison between patients, families, and physicians to determine the next level of care.
  • Coordinating the transition from inpatient care to post-hospital care, ensuring responsive and appropriate services are provided after discharge.
  • Documenting care plans and utilization issues in designated systems, including case management software and multidisciplinary care documents.
  • Evaluating the effectiveness of care plans to ensure progress toward desired patient outcomes.
  • Initiating interventions pre-hospital, during hospitalization, and post-discharge based on proactive assessments and referrals from the healthcare team.
  • Making timely referrals to other healthcare professionals, including quality improvement teams, risk managers, social workers, and home services.
  • Performing nursing activities related to assessment, coordination, planning, monitoring, implementation, and evaluation, while providing support and education to clients and families.
  • Investigating coverage options for post-hospital needs and presenting these to patients and providers.
  • Overseeing the acute care plan to ensure the coordination and completion of services that meet post-hospitalization requirements.
  • Leading interdisciplinary teams to achieve organizational objectives related to length of stay and readmission rates.
  • Tracking avoidable inpatient stay days and conducting readmission assessments.
  • Assessing patients for their needs post-discharge and participating in daily care rounds.
  • Arranging necessary services such as durable medical equipment, home care, hospice, and transportation.
  • Facilitating patient and family care conferences as needed.
  • Participating in departmental workgroups to enhance care delivery.

Qualifications:

Educational Requirements:
Associate's Degree in Nursing is required, with a Bachelor's Degree in Nursing to be obtained within five years of hire.

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

Experience:
A minimum of three years in a related field is required.

Additional Requirements:
Completion of all required continuing education regarding the care of acute stroke patients is necessary.

Skills and Knowledge:
The ideal candidate will demonstrate the ability to establish professional relationships with healthcare providers, work independently and collaboratively, possess strong communication and organizational skills, and have a keen attention to detail while managing multiple patient cases concurrently.

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.

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