RN Care Transition Specialist — Discharge & Continuity

Carle; Urbana (IL); On-site; USD 50,000 - 80,000; Full time

Job summary

Carle Health is seeking an experienced Case Manager/RN to oversee clinical and financial outcomes during acute illness requiring hospitalization. You will coordinate discharge planning, assess needs, and lead multidisciplinary rounds at the bedside to ensure safe, timely transitions.

The role emphasizes proactive assessment, care coordination, and collaboration with physicians, therapists, and home services to reduce readmissions and optimize length of stay.

Qualifications

• Licensed Registered Nurse (RN) in Illinois (IDFPR).
• Accredited Case Manager (ACM) within 3 years (ACMA).
• Basic Life Support (BLS) certification (AHA) within 30 days.
• College Diploma in Nursing (Required).

Responsibilities

• Act as liaison with patient/family and physician to determine next level of care.
• Conduct case review presentations to educate peers on unique or challenging cases.
• Coordinate the transition from inpatient care to post-hospital care with pre- and post-hospital providers.
• Document plan of care and utilization issues in case management software and the multidisciplinary plan of care.
• Evaluate effectiveness of plan of care toward desired patient outcomes.
• Initiate interventions pre-hospital, in-hospital, and post-hospital for identified patients and families.
• Initiate timely referrals to other health care team members.
• Perform nursing activities of assessment, coordination, planning, monitoring, implementation, and evaluation.
• Interact with clients, caregivers and families to assess, plan care, arrange services, monitor, and educate.
• Investigate coverage for post-hospital needs and present options.
• Oversee acute setting plan of care to meet post-hospital needs.
• Lead interdisciplinary team to improve length of stay and readmissions.
• Track avoidable days on inpatient stays and readmission assessments.
• Assess patients for post-discharge needs and participate in daily rounds.
• Arrange DME, Home Care, Hospice, SNF, and Transportation.
• Assist patient/family care conferences and participate in department work groups.
• HRHC: follow up with PCPs before discharge; post-discharge calls and prior authorizations for swing bed patients.
• RMH: follow up with PCPs before discharge and post-discharge calls.

Skills

Case management

Interdisciplinary coordination

Patient advocacy

Education

Nursing Diploma

Job description

Carle Health is seeking an experienced Case Manager/RN to oversee clinical and financial outcomes during acute illness requiring hospitalization. You will coordinate discharge planning, assess needs, and lead multidisciplinary rounds at the bedside to ensure safe, timely transitions.

The role emphasizes proactive assessment, care coordination, and collaboration with physicians, therapists, and home services to reduce readmissions and optimize length of stay.