RN Clinical Transitions & Care Coordinator

Carle Health; Peoria (IL); On-site; USD 4,941,000 - 167,253,000; Full time

Job summary

Carle Health is seeking an experienced RN Case Manager to oversee the functional and financial outcomes during acute illness requiring hospitalization. You will ensure proactive initial assessments, ongoing evaluations, and timely discharge planning, guiding safe transitions from hospital to appropriate next care.

This role relies on the five case management components: assessment, coordination, monitoring, implementation, and evaluation.

Qualifications

• Licensed Registered Professional Nurse (RN) - Illinois IDFPR
• Bachelor's Degree required

Responsibilities

• Act as liaison with patient/family and physician to determine next level of care
• Coordinate transition from inpatient care to post-hospital care with physicians and referrals
• Document plan of care and utilization issues in case management systems
• Evaluate plan of care and collaborate with physicians to ensure outcomes and reduce readmission risk
• Investigate coverage for post-hospital needs and present options to patient/family and provider
• Initiate interventions for pre-hospital, in-hospital, and post-hospital stages for identified patients
• Participate in multidisciplinary rounds and coordinate referrals to care team members
• Perform case management activities across assessment, coordination, planning, monitoring, implementation, and evaluation
• Interact with clients and families to assess, plan, arrange services, monitor and educate
• Provide oversight of acute setting care plan to ensure post-hospital needs are met
• Conduct case review presentations to educate peers on complex cases
• Track avoidable inpatient days and readmission risk and plan accordingly
• Assess post-discharge needs within 24-48 hours of admission and throughout the stay
• Arrange DME, Home Care, outpatient infusion and coordinate with social work for Hospice/ECF/Transportation
• Attend patient/family care conferences as needed

Education

Bachelor's Degree

Job description

Carle Health is seeking an experienced RN Case Manager to oversee the functional and financial outcomes during acute illness requiring hospitalization. You will ensure proactive initial assessments, ongoing evaluations, and timely discharge planning, guiding safe transitions from hospital to appropriate next care.

This role relies on the five case management components: assessment, coordination, monitoring, implementation, and evaluation.