Care Coordinator - Sickle Cell Adult and Pediatrics

Cleveland Clinic

1d•Hybrid

About The Position

Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world class and caregivers are family. Here, you will work alongside a passionate and dedicated team, 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 supporting Sickle Cell Adult and Pediatric patients, you will collaborate with multidisciplinary caregivers across the continuum of care to provide longitudinal care coordination and disease management for patients with chronic conditions. In this role, you will triage patient concerns to ensure timely resolution and appropriate 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 role works a hybrid schedule from 8:00 a.m. -- 4:30 p.m., typically split approximately 60/40 between on-site at Main Campus and remote work, though this may shift closer to 70/30 on-site depending on provider coverage needs. Clinic coverage may occasionally require extension when clinics run late. Occasional work outside core hours may also be required due to education sessions or shared medical appointments occurring after clinic time (typically monthly or quarterly).

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
Sickle cell experience
Hematology/Oncology experience
ER and/or pain management 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.