Care Coordinator - Colorectal Surgery

Cleveland Clinic

10d • Hybrid

About The Position

Join our team at Cleveland Clinic and experience world-class healthcare at its best. Named one of the top digestive disease centers in the nation, our Digestive Disease and Surgery Institute (DDSI) is the first of its kind to unite all specialists in gastroenterology and hepatology, bariatric surgery, colorectal surgery, hepato-pancreato-biliary and transplant surgery, and nutrition within one unique, fully integrated model of care. This innovative model of care is aimed at optimizing the patient experience. Here, you can work with a team of talented caregivers that provide the most advanced, safest and clinically proven treatments of the gastrointestinal tract. The RN Care Coordinator provides ongoing disease management, proactive patient outreach, and education/coaching to support self-management and reduce avoidable emergency department visits and hospital readmissions. This role closely monitors patient progress toward care goals, facilitates smooth transitions across care settings, and contributes to improved patient satisfaction. This position will support colon and rectal surgery. This is a hybrid role offering the ability to work from home 2 days per week. A caregiver in this position works days, 8:00am to 5:00pm. A caregiver who excels in this role will: 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. Conduct comprehensive clinical assessments that include disease/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.

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)
• Specialty certification

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.
• Conduct comprehensive clinical assessments that include disease/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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees