RN – Transitional Care Clinic

Utilizes a systemic approach to nursing by incorporating assessment, planning, implementation and evaluation in the practice of nursing. Provides and facilitates healthcare and transitions of care to individuals, families and communities within the RN scope of practice as defined by the Illinois Department of Nursing.

• Provides and facilitates competent health care of patients and families in area of practice. Ensures adherence to established standards of care and scope of practice.
• Ensures documentation of care is complete and accurate.
• Provides health and wellness education to individuals and groups.
• Assists nursing supervisor in the development of departmental protocols, policies and procedures. Provides leadership for initiatives designed to improve the quality of care or clinical outcomes.
• Coordinate with patient scheduling, referrals, handoffs, intake, assessment and provide continuity of team resources.
• Provide care management, facilitate transitions of care, support home visits for high risk patients. Communicate with PCP and other team members to ensure continuity of care, both within the Carle system and external to the Carle system
• Outreach to patients to collect pre-visit information, verify medications and allergies, collect vital signs, administer medications and fluids and document all clinical assessments and interactions. Complete pre-authorization and needed insurance documentation.
• Perform assessment, vital signs and complete necessary screening for patients presenting to the Transitional Care Clinic (TCC).
• Complete intake phone calls for patients scheduled for the TCC.
• Triage phone calls using Adult Telephone Protocol, 3rd edition
• Schedule appointments as ordered by provider.
• Assist with auditing patient records for compliance to TCC requirements.
• Follow up and document on inbasket notes and requests.