Clinical Transition Specialist RN - Emergency Department

Carle Health•Urbana, IL

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 assessment of patient needs, ongoing evaluation, and timely initiation of discharge planning, facilitating a safe transition from the hospital to an appropriate level of care. It uses 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 role coordinates inpatient-to-post-hospital transitions, collaborates with patients, families, physicians, and pre- and post-hospital providers, and helps ensure appropriate post-discharge care. It leads interdisciplinary efforts to support organizational goals for length of stay and readmissions, assesses post-discharge needs, tracks avoidable inpatient days, and conducts readmission assessments. Depending on the site, responsibilities include arranging follow-up appointments and post-discharge calls, and obtaining prior authorizations and addressing denials for swing-bed patients. Carle Health describes itself as a healthcare organization with more than 17,000 team members and providers, seven hospitals across eight campuses, and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. The position's compensation range is $35.87 to $58.37 per hour. Carle Health offers a comprehensive benefits package; further details are available on its benefits website.

Requirements

Licensed Registered Professional Nurse (RN) in Illinois through the Illinois Department of Financial and Professional Regulation.
College diploma in Nursing.
Obtain Accredited Case Manager (ACM) certification within 3 years.
Obtain Basic Life Support (BLS) certification through the American Heart Association 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 about 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 plans of care and utilization issues in appropriate locations, including case management/utilization review software and multidisciplinary plan-of-care documents.
Evaluate the effectiveness of plans of care and progress toward desired patient outcomes.
Initiate pre-hospital, in-hospital, and post-hospital interventions for patients and families identified through admission assessment or referrals from the healthcare team.
Make timely referrals to other healthcare team members, including quality improvement, risk management, social work, physicians, and Home Services.
Perform nursing activities including assessment, coordination, planning, monitoring, implementation, and evaluation.
Assess, plan care, arrange services, monitor, and provide support and education to clients, caregivers, and families.
Investigate coverage for post-hospital needs and present options to patients, families, and providers.
Oversee acute-setting plans of care to coordinate and complete services needed after hospitalization.
Lead an interdisciplinary team in achieving organizational goals related to length of stay and readmissions.
Track avoidable days during inpatient stays and assess inpatient readmissions.
Assess patients for post-discharge needs and participate in daily whiteboard rounds.
Arrange durable medical equipment, home care, hospice, extended-care or skilled-nursing facilities, and transportation.
Assist with patient and family care conferences and participate in department work groups.
At HRHC, make primary-care follow-up appointments before discharge and make post-discharge calls to check on patients and their needs.
At RMH, make primary-care follow-up appointments before discharge and make post-discharge calls to check on patients and their needs.
For swing-bed patients, obtain prior authorizations, maintain work queues, and address denials.