RN Care Coordinator – Asthma

Cleveland Clinic•Cleveland, OH

6d•Hybrid

About The Position

At Cleveland Clinic's Respiratory Institute, we provide world-class patient care by combining our strengths in clinical care, research and education. With more than 170 pulmonologists, allergists/immunologists, infectious disease experts and critical care specialists, the Respiratory Institute staff diagnose and treat a wide spectrum of disorders in our outpatient offices, inpatient hospital floors, and intensive care units. We treat over 200,000 patients annually in our outpatient clinics and Cleveland Clinic is recognized in the U.S. and throughout the world for its expertise and care. The Pulmonary Medicine Department specializes in the prevention, diagnosis, treatment, and long-term management of diseases affecting the lungs and respiratory system. At Cleveland Clinic, pulmonary providers care for patients at both the Main Campus Hospital and Family Health Centers, allowing patients to receive specialty care close to home while still having access to the expertise of the flagship medical center. Cleveland Clinic Care Coordinators have been very successful in helping patients manage their own care. In this role, your dedication and commitment can decrease Emergency Department visits, observation status, inpatient stays and hospital readmission. Not only do you coordinate services and offer medical advice, but you can also provide comfort and reassurance to patients as they navigate their illness or disease. This position offers a unique opportunity to enhance the Cleveland Clinic experience and leave a lasting impression on their lives, their families and the community, all while further expanding your own nursing skills and growth.

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
Strong attention to detail and therapeutic communication skills

Nice To Haves

Bachelor’s of Science in Nursing (BSN)

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.
Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved.
Utilize technological tools (registries, patient lists, care team tab, etc.) to manage population
Use assessment skills and 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.
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.
Define and ensure compliance with disease-specific care paths for specialty care or chronic disease.
Work with the patients and family to assess current knowledge, health literacy, and readiness to change, utilizing teach back to assess level of knowledge.
Coach patient and family on self-management support; including setting long and short term goals.
Educate about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks.
Work with practices on quality and process improvement initiatives.