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Carle Health · 2 months ago

Clinical Transitions Specialist RN - Case Management

Normal, IL

Full-time

Onsite

Mid Level

$34.01/hr - $58.50/hr

Carle Health is a healthcare system with nearly 16,600 team members, and they are seeking a Clinical Transitions Specialist RN for case management. This role is responsible for the oversight and coordination of patient care during the transition from acute hospitalization to appropriate post-hospital care, ensuring patients receive the necessary assessments and planning for safe discharge.

Hospital & Health Care

Responsibilities

Act as a liaison working with patient/family and physician to determine next level of care and manage LOS

Coordinates the transition from inpatient care to post-hospital care, collaborating with physicians, consultants, internal and external referrals to facilitate appropriate next level of care to meet patient goals and outcomes

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 and collaborates with physicians to ensure the progression toward desired patient outcomes while managing risk for readmission and length of stay

Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider

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 healthcare team

Participates in multidisciplinary rounds and initiates timely referrals to other internal healthcare team members (quality improvement, risk manager, social workers, pharmacy, therapy services, etc.)

Performs case management 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

Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs

Conducts case review presentations to educate peers on unique or challenging cases and scope of practice issues

Track avoidable days on inpatient stays

Readmission assessment of inpatient stays

Assess patients for post discharge needs within 24-48 hours of admission and ongoing through out the stay

Assess patients risk for readmission and navigate strategies with patient and family to reduce risk through post acute planning

Arrange DME, Home Care, outpatient infusion and coordinate with social work for Hospice, ECF Placement, and Transportation

Deliver or delegate delivery of regulatory letters for Medicare and observation patients

Arrange/attend any patient/family care conferences

Qualification

Accredited Case ManagerBachelor's Degree NursingCase ManagementPatient AssessmentCare CoordinationSoft Skills

Required

Accredited Case Manager (ACM) within 3 years - American Case Management Association (ACMA)

Bachelor's Degree: Nursing

Benefits

Comprehensive benefits package

Company

Carle Health

Glassdoor3.6

Carle Health is a vertically integrated system with a bold but simple mission: to be the trusted partner in all healthcare decisions for everyone who depends on it.

Founded in 1946