This position serves in an expanded nursing role working in collaboration with the division hospital team, primary care physicians and patient to provide a transition of care model that is conducive to the delivery of quality, efficient, and cost-effective healthcare services. Primary focus is on transitions from the hospital to home and long-term care facility.

Direct Patient Care 75%

1. Works under the direction of the CFM Hospital Team providing nursing support to assist with and bridge gaps between the inpatient and outpatient settings.
2. Serves as an extension of the CFM hospital team, establishing rapport with the patient and/or caregiver to ensure hospital discharge appointments are made and the importance of the visit
3. Provides patient education in anticipation of discharge and assists residents and attending provider with discharge documentation
4. Attend in-patient rounds to gain understanding of and participate in the patient's care and treatment. Assists team in proactively identifying care needs or linking with applicable services to facilitate transition home or to another facility
5. With the health care team, identifies patients at higher risk for readmission and assures coordinated efforts are made to break down barriers and implements a patient-centered, nursing plan of care that promote health improvements
6. Provides telephone triage for all incoming calls from patients, pharmacies and other health care agencies regarding care of discharged patients
7. Places follow-up calls to patients within 2 days of discharge to confirm status, reconcile meds, identify any immediate concerns and problem solve any treatment gaps identified
8. Conducts additional follow-up calls as needed during the initial post-discharge phase to support patient's goals, reassess patients progress and barriers toward goals and provide further patient education as identified
9. Communicates with hospital team and/or PCP to ensure patient follow-up
10. Assists in reconciling med lists between the hospital discharge summary and the clinic EHR at the direction of the hospital attending
11. Maintains accurate, up to date documentation for all case management activities

1. Provides annual and monthly orientation for residents and students regarding in-patient services
2. Assists in collection and analysis of data for hospital project targets and projected outcomes
3. Participates on internal quality improvement teams
4. Participates on quality improvement committees in the Center as well as externally through the school and at the hospital

1) Possession of a valid license as a Licensed Practical Nurse issued by the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation; AND
2) 6 months of nursing experience in a health care facility (such as a hospital, nursing home, medical clinic, prison, mental health facility, or closely related facilities)
Condition of Employment: Pursuant to the State Universities Civil Service System, an out-of-state resident who is hired into this position must establish Illinois residency within 180 calendar days of their start date.

If you require assistance, please contact the Office of Human Resources at or call 217-545-0223 Monday through Friday, 8:00am-4:30pm.

The mission of Southern Illinois University School of Medicine is to optimize the health of the people of central and southern Illinois through education, patient care, research and service to the community.
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"Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act."

Southern Illinois University School of Medicine is an Affirmative Action/Equal Opportunity employer who provides equal employment and educational opportunities for all qualified persons without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, protected veteran status or marital status in accordance with local, state and federal law.

Pre-employment background screenings required.