Care Coordinator - Hepatology

Cleveland Clinic•West Palm Beach, FL

5d•Onsite

About The Position

Join the Cleveland Clinic West Palm Beach team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. Cleveland Clinic Care Coordinators have been very successful in helping patients manage their own care. Their hard work, dedication and commitment have led to a decrease in Emergency Department visits, observation status, inpatient stays and hospital readmission in care coordinated patients. As a Care Coordinator in our Hepatology Unit, 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). Ultimately, your efforts will improve care for patients at home and reduce readmission. 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 role works Monday through Friday from 8:00 a.m. – 5:00 p.m.

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)
Three to five years of nursing experience

Nice To Haves

Bachelor of science in nursing (BSN)
Specialty certification
Care coordination experience

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.