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Clinical Transition Specialist RN - Weekend Program

CARLE • Macon, IL 62544 • Posted 3 days ago

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In-person • Full-time • Mid Level

Job Highlights

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The Clinical Transition Specialist RN at CARLE is responsible for overseeing, coordinating, and managing the functional and financial outcomes during acute illness requiring hospitalization for patients at Carle Foundation Hospital. This role ensures proactive initial assessment, ongoing evaluations, and initiation of discharge planning to facilitate a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. The specialist acts as a liaison between patients, families, and physicians, coordinates transitions from inpatient to post-hospital care, and leads interdisciplinary teams to achieve organizational goals.

Responsibilities

  • Oversee, coordinate, and manage functional and financial outcomes during hospitalization.
  • Ensure proactive initial assessment, ongoing evaluations, and initiation of discharge planning.
  • Act as a liaison between patients/families and physicians to determine next level of care.
  • Conduct case review presentations to educate peers on unique or challenging cases.
  • Coordinate transition from inpatient care to post-hospital care with pre- and post-hospital providers.
  • Document plan of care and utilization issues in appropriate software and documents.
  • Evaluate effectiveness of plan of care to ensure progression toward desired outcomes.
  • Initiate interventions for patients and families identified from admission assessment or referrals.
  • Initiate timely referrals to other health care team members.
  • Perform nursing activities including assessment, coordination, planning, monitoring, implementation, and evaluation.
  • Investigate coverage for post-hospital needs and present options to patient/family and provider.
  • Provide oversight of acute setting plan of care.
  • Lead an interdisciplinary team to achieve goals related to length of stay and readmissions.
  • Track avoidable days on inpatient stays and assess readmission of inpatient stays.
  • Arrange DME, Home Care, Hospice, returns to ECFs, and Transportation.

About CARLE

Carle Health is a healthcare organization operating in Illinois, offering a wide range of services including clinical care, health insurance, research, and academics. They have a team of nearly 16,500 members providing high-quality care through eight hospitals, physician group practices, health insurance plans, and medical education institutions, with a focus on innovation, diversity, and community impact.

Full Job Description

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.
  • 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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