Nightingale RN Care Coordinator - Oncology

Cleveland Clinic

5d•Onsite

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. 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. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will work alongside passionate and 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 Registered Nurse Care Coordinator, you will work collaboratively with the multidisciplinary care team staff for high-risk patients. You will provide care and disease management to patients with chronic conditions or episodic care of a surgical population. Your duties will include: • Utilizing technological tolls to manage the population of patients. • Performing assessments and reassessments regarding patients' progress towards goals and update care plans. • Identifying which specialty care practice patients have ongoing care coordination needs per condition. • Studying and outlining the nature and duration of involvement needed by the specialty care team and coordinator involved. A caregiver in this position works 8:00AM - 5:00PM, at least 48 hours every 6 weeks on a as needed PRN basis. The ideal future caregiver is someone who: • Minimum of 3 years experience in the Care Coordinator role at Cleveland Clinic prior to retirement. • Comes prepared with a positive attitude and demonstrates strong self-motivation. • Has strong communication skills and interpersonal skills. • Can work in a close-knit, teambuilding community. • Is currently registered as a Registered Nurse and has a Basic Life Support certification. At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.

Requirements

Graduate from an accredited school of professional nursing.
Current state licensure as a Registered Nurse (RN).
Basic Life Support (BLS) through American Heart Association (AHA).
Three to five years of nursing experience required.
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
Requires full range of motion, manual and finger dexterity and eye-hand coordination.
Requires corrected hearing and vision to normal range.
May requires some exposure to communicable diseases or bodily fluids.
For Homecare and Hospice field staff only, must have valid Ohio Driver’s license upon hire; per policy 8-175 thereafter.
For Homecare and Hospice field staff only, must have proof of automobile insurance coverage with $100,000/$300,000 coverage, upon hire; per policy 8-175 thereafter.

Nice To Haves

BSN preferred.
Specialty certification preferred.
Minimum of 3 years experience in the Care Coordinator role at Cleveland Clinic prior to retirement.
Comes prepared with a positive attitude and demonstrates strong self-motivation.
Has strong communication skills and interpersonal skills.
Can work in a close-knit, teambuilding community.

Responsibilities

Identifies which patients in the specialty care practice have ongoing care coordination needs for their specialty condition.
Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved.
Utilizes assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of social support, readmissions, ED visits, surgical episodes, etc.) to ensure timely and efficient care delivery across the continuum of care.
Utilizes technological tools (registries, patient lists, care team tab, etc.) to manage populations.
Conducts comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral pharmacy, social and end of life needs of each patient.
Informs the patient and family regarding coordination of their care and shares this information with the healthcare team.
Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
Monitors patient compliance with plan of care.
Performs reassessments regarding patient progress toward goals and updates plan of care as appropriate.
Ensures care gaps are closed around specialty disease/chronic disease/surgical episodes.
Serves as primary patient contact for team related to condition/surgical episode and facilitates access to services.
Coordinates members of the patient care team.
Serves as the liaison between patients, families, and physicians, clinical staff by advocating for patient and families then responding to and facilitates resolution of patient/family questions and concerns.
Assists in managing transitions of care across care setting, ensuring optimal communication and planning.
Identifies barriers to receiving care and facilitates solutions.
Partners with other care coordinator teams such as primary and transitional care social work, rehabilitation, pharmacy, palliative care and others.
Defines and ensures compliance with disease-specific care paths for specialty care or chronic disease.
Works with the patient and family to assess current knowledge, health literacy, and readiness to change, utilizing teach back to assess level of knowledge.
Coaches patient and family on self-management support; including setting long and short term goals.
Educates about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks.
Educates and connects to other care providers and community resources to enhance care.
Works with practices on quality and process improvement initiatives.
In home care only, this role oversees and directs clinical staff and a team of LPNs to ensure patients receive appropriate services.
Other duties as assigned.