RN Acute Care Transitions Specialist

Carle; Peoria, Northern (IL, KY); Hybrid; USD 50,000 - 80,000; Full time

Job summary

Carle Health is seeking a Registered Nurse with case management responsibilities to oversee and coordinate outcomes during acute hospitalization. You will assess needs, plan care, and facilitate safe discharge planning from the hospital to appropriate post-acute settings.

The role emphasizes assessment, coordination, monitoring, and evaluation across the care continuum, with collaboration among physicians, social workers, and therapy services to optimize patient outcomes.

Qualifications

• Licensed RN in Illinois (IDFPR) is required.
• Bachelor's degree in a related field is required.

Responsibilities

• Act as liaison with patient/family and physician to determine next level of care.
• Coordinate transition from inpatient to post-hospital care with providers.
• Document plan of care and utilization issues in case management systems.
• Evaluate plan effectiveness and collaborate with physicians to reduce readmission risk.
• Initiate post-acute planning and coordinate with social work and therapy services.
• Participate in multidisciplinary rounds and refer to care teams as needed.
• Track avoidable inpatient days and conduct readmission assessments.

Skills

Case management

Care coordination

Patient advocacy

Education

RN licensure (IDFPR)

Bachelor's degree

Job description

Carle Health is seeking a Registered Nurse with case management responsibilities to oversee and coordinate outcomes during acute hospitalization. You will assess needs, plan care, and facilitate safe discharge planning from the hospital to appropriate post-acute settings.

The role emphasizes assessment, coordination, monitoring, and evaluation across the care continuum, with collaboration among physicians, social workers, and therapy services to optimize patient outcomes.