Clinical Transition Specialist RN - Emergency Department

Carle Health•Urbana, IL

15h

About The Position

The Clinical Transition Specialist RN oversees, coordinates, and manages functional and financial outcomes for patients of Carle Foundation Hospital during acute illness requiring hospitalization. The role ensures proactive initial assessment, ongoing evaluation, and discharge planning to support a safe and timely transition from the hospital to an appropriate level of care outside the hospital. It applies the five components of case management: assessment, coordination, monitoring, implementation, and evaluation. The specialist participates in daily multidisciplinary bedside rounds to support timely planning and collaboration. The position coordinates inpatient-to-post-hospital transitions with patients, families, physicians, and pre- and post-hospital providers. It assesses post-discharge needs, develops and evaluates care plans, arranges services, investigates coverage, initiates referrals and interventions, and provides support and education. Depending on the assigned setting, responsibilities may also include scheduling follow-up appointments, making post-discharge calls, obtaining prior authorizations for swing bed patients, maintaining work queues, and addressing denials.

Requirements

College diploma in Nursing.
Licensed Registered Professional Nurse (RN) through the Illinois Department of Financial and Professional Regulation (IDFPR).
Obtain Accredited Case Manager (ACM) certification through the American Case Management Association (ACMA) within 3 years.
Obtain Basic Life Support (BLS) certification through the American Heart Association (AHA) within 30 days.

Responsibilities

Act as a liaison among patients, families, and physicians to determine the next level of care.
Present case reviews to educate peers on unique or challenging cases and scope-of-practice issues.
Coordinate transitions from inpatient care to post-hospital care with pre- and post-hospital providers.
Document the plan of care and utilization issues in appropriate locations, including case management/utilization review software and the multidisciplinary plan-of-care document.
Evaluate the effectiveness of care plans and progress toward desired patient outcomes.
Initiate pre-hospital, in-hospital, and post-hospital interventions for patients and families identified through admission assessments or team referrals.
Make timely referrals to health care team members, including quality improvement, risk management, social work, physicians, and Home Services.
Assess, coordinate, plan, monitor, implement, and evaluate nursing care; work with clients, caregivers, and families to arrange services and provide support and education.
Investigate coverage for post-hospital needs and present options to patients, families, and providers.
Oversee the acute-setting plan of care to ensure services are coordinated and completed to meet post-hospitalization needs.
Lead an interdisciplinary team toward organizational goals related to length of stay and readmissions.
Track avoidable days during inpatient stays and assess inpatient readmissions.
Assess patients' post-discharge needs.
Participate in daily whiteboard rounds.
Arrange durable medical equipment, Home Care, Hospice, extended care or skilled nursing facility placement, and transportation.
Assist with patient and family care conferences.
Participate in department work groups.
For HRHC assignments, schedule primary care follow-up before discharge, make post-discharge calls, obtain prior authorizations for swing bed patients, maintain work queues, and address denials.
For RMH assignments, schedule primary care follow-up before discharge and make post-discharge calls to check that patients are doing well and have what they need.