Care Coordinator RN Nurse Navigator

Cleveland Clinic•West Palm Beach, FL

1d•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. As a Care Coordinator RN Nurse Navigator, you will collaborate with Emergency Department physicians and a multidisciplinary care team to coordinate care for high-risk patients across the continuum of care. In this role, you will support ED provider-led patient management by conducting patient outreach, facilitating care coordination, and providing longitudinal disease management for patients with chronic conditions or episodic healthcare needs. You will work to ensure seamless transitions of care, promote wellness, reduce preventable emergency department visits and hospital readmissions, and enhance patient satisfaction through timely communication and coordination with patients, providers, and community resources.

Requirements

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

Nice To Haves

Bachelor’s of Science in Nursing (BSN)
Specialty certification
Outpatient/Hospital experience
Emergency Department experience
ACLS certification through the American Heart Association (AHA) or the American Red Cross
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.
Assist and support in the care coordination led by the ED provider.
Ensure the chart contains the necessary information for the patient and is updated as needed (med lists, PCP, recent care in other hospitals, preferred pharmacies, etc.).
Assist in real-time communication with the patient and their family when ED visits or clinical evaluations are required.
Collaborate with local West Palm Beach Emergency Departments when patients are present for acute care, serving as the primary liaison between emergency providers and patients to ensure seamless communication and continuity of care.
Follow-up calls on the status of a patient after being discharged from a health facility.
Communicate with pharmacies (as needed) for prescriptions.
Ensure diagnostic results are shared with the necessary clinical team members of the patient.
Secure necessary follow-up appointments.
Be available for on call at all times - relief coverage provided.