Clinical Transitions Spec RN - CMH IP Clin Case Mgmt

Overview Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of Carle Health. 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. 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. Qualifications Certifications: Licensed Registered Professional Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR). Education: Bachelor’s Degree. Work Experience: (to be specified). Salary Range The compensation range for this position is $34.01 per hour – $58.50 per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered to a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee’s Form I-9 to confirm work authorization. For more information: View email address on click.appcast.io. #J-18808-Ljbffr