RN - Clinical Transitions Specialist
Company: Carle Health
Location: Peoria
Posted on: April 3, 2026
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Job Description:
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. Qualifications Certifications: Licensed Registered
Professional Nurse (RN) - Illinois Department of Financial and
Professional Regulation (IDFPR)Illinois Department of Financial and
Professional Regulation (IDFPR), Education: Bachelor's Degree, Work
Experience: 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. About Us Find it here. Discover
the job, the career, the purpose you were meant for. At Carle
Health, we're committed to fostering a workplace where every team
member feels valued, respected and empowered, where passion and
purpose come together to positively impact the lives of our
patients and our communities. Find it all at Carle Health. Our
nearly 17,000 team members and providers work together to support
patient care across central and southeastern Illinois. We’ve grown
to include eight, award-winning hospitals and a multispecialty
provider group with more than 1,500 doctors and advanced practice
providers. We’re developing the next generation of providers and
healthcare professionals through Carle Illinois College of
Medicine, the world’s first engineering-based medical school, and
Methodist College. Carle BroMenn Medical Center, Carle Foundation
Hospital, Carle Health Methodist Hospital, Carle Health Proctor
Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional
Health Center hold Magnet® designations, the nation’s highest honor
for nursing care. We offer opportunities in several communities
throughout central Illinois with potential for growth and life-long
careers at Carle Health. 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: human.resources@carle.com. Compensation and Benefits
The compensation range for this position is $34.01per hour -
$58.5per 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 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. To learn more
visit careers.carlehealth.org/benefits.
Keywords: Carle Health, Champaign , RN - Clinical Transitions Specialist, Healthcare , Peoria, Illinois
