Care Coordinator - Chronic Care

Cleveland Clinic

19h•Hybrid

About The Position

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Details Join Cleveland Clinic’s Martin North Hospital where research and surgery are advanced, technology is leading-edge, patient care is world-class, and caregivers are family. This downtown Stuart hospital provides top-quality patient care to the communities in and around Martin County on the beautiful St. Lucie River. The caregivers at Martin North Hospital have made it an excellent medical facility and a home away from home. As a Care Coordinator, you will work collaboratively with multidisciplinary caregivers across the continuum of care to provide coordination of care and disease management longitudinally to patients with chronic condition(s). You will work to ensure patient concerns are appropriately triaged to facilitate timely resolution and provider involvement when necessary. Ultimately, your efforts will focus on enhancing treatment outcomes and decreasing future Emergency Department visits for your patients. On this team, you will learn something new every day, grow in your field, and gain access to numerous professional development resources. A caregiver in this position works days from 8:00AM – 5:00PM. After the on-site training period, this caregiver will work remotely. Living within two hours of Martin North Hospital is required.

Requirements

Graduate from an accredited school of Professional Nursing
Current state licensure as a Registered Nurse (RN)
Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
Three to five years of nursing experience

Nice To Haves

Bachelor’s of Science in Nursing (BSN)
Four to five years of bedside nursing experience
Nursing experience in the ICU
EPIC experience
Specialty certification
Fluent in Spanish

Responsibilities

Work collaboratively with a multidisciplinary care team across the continuum of care for high-risk patients to develop goals, plan interventions and maximize patient outcomes.
Provide care and disease management coordination.
Identify patients in the specialty care practice that have ongoing coordination needs and conduct targeted outreach.
Outline the nature and duration of involvement needed by the specialty care team and specialty care coordinator and identify the primary care team involved.
Utilize assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
Utilize technological tools (registries, patient lists, care team tab, etc.) to manage populations.
Conduct comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.
Inform and work with patients and their families regarding coordination of their care, provide education and coaching, monitor patient compliance with their care plan, perform reassessments regarding patient progress toward goals and update plan of care.
Serve as a liaison and advocate for patients and families.
Assist in managing transitions of care across care settings, ensuring optimal communication and planning.
Identify barriers, facilitate solutions and connect others to community resources.
Partner with other care coordinator teams such as primary and transitional care social work, rehabilitation, pharmacy, palliative care and others.
Define and ensure compliance with disease-specific care paths for specialty care or chronic disease.
Coach patient and family on self-management support.
Educate about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks.
Educate and connect to other care providers and community resources to enhance care.