RN Clinical Transitions Specialist – Inpatient Case Management

Carle Health

. Oversee, coordinate, and manage functional and financial outcomes during acute hospitalization .

Posted 9/25/2026full-timePeoria • Illinois • United StatesMid-LevelSenior💰 $36 - $58 per hourWebsite

About the role

Key responsibilities & impact

Oversee, coordinate, and manage functional and financial outcomes during acute hospitalization
Perform proactive initial assessments, ongoing evaluations, and discharge planning
Facilitate safe and timely transitions from acute care to appropriate post-hospital care
Act as liaison among patients, families, physicians, consultants, and internal and external referral resources
Coordinate transitions from inpatient to post-hospital care
Document plans of care and utilization issues in case management software and multidisciplinary care documents
Evaluate care plans and collaborate with physicians to support patient outcomes while managing readmission risk and length of stay
Investigate coverage for post-hospital needs and present options to patients, families, and providers
Initiate pre-hospital, in-hospital, and post-hospital interventions
Participate in multidisciplinary rounds and make timely referrals to healthcare team members
Assess, plan, arrange services, monitor, implement, evaluate, and provide support and education
Track avoidable inpatient days and conduct readmission assessments
Assess post-discharge needs within 24–48 hours of admission and throughout the stay
Develop post-acute strategies to reduce readmission risk
Arrange durable medical equipment, home care, outpatient infusion, hospice, extended care facility placement, and transportation
Deliver or delegate regulatory letters for Medicare and observation patients
Arrange and attend patient/family care conferences
Present unique or challenging cases and scope-of-practice issues to peers

Requirements

What you’ll need

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Bachelor's Degree
Monday through Friday schedule
Weekend requirements on rotation
Holiday requirements on rotation
No on-call requirement

Benefits

Comp & perks

Comprehensive benefits package
Opportunities for growth and life-long careers