Inpatient RN - Care Coordinator
Posted on: October 9, 2021
Responsible for the oversight, coordination, and management of
the functional and financial outcomes during acute illness
requiring hospitalization for patients of the Carle Foundation
Hospital. 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
- Act as a laison working with patient/family and physician to
determine next level of care
- Conducts case review presentations to educate peers on unique
or challenging cases and scope of practice issues.
- Coordinates the transition from inpatient care to post-hospital
care, working with pre- and post- hospital providers to ensure
responsive and appropriate care is provided post-discharge.
- 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 to ensure
the progression toward desired patient outcomes.
- 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.
- Initiates timely referrals to other healthcare team members
(quality improvement, risk manager, social workers, physicians,
Home 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
- Proactively investigates coverage for post-hospital needs and
presents options to the patient/family and provider.
- Provides oversight of acute setting plan of care to ensure
coordination and completion of services to meet
- Track avoidable days on inpatient stays.
- Readmission assessment of inpatient stays.
- Assess patients for post discharge needs.
- Do secondary screening (trans plan evaluations ) on high risk
- Attend daily white board rounds
- Arrange DME, Home Care, Hospice, ECF Placement, and
- Deliver Observation Notification letters to patients who are
observation when needed.
- Arrange/attend any patient/family care conferences.
Keywords: CARLE, Normal , Inpatient RN - Care Coordinator, Other , Normal, Illinois
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