RN Care Coordinator - Pulmonary Disease

Cleveland Clinic • Weston, FL

149d

About The Position

Join Cleveland Clinic Weston Hospital's team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic's Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. As an RN Care Coordinator for the Advanced Pulmonary and Lung Disease programs, your focus will be on patient outreach and ongoing coordination for a panel of patients to achieve optimal health outcomes, promote wellness, reduce preventable emergency department visits and hospital readmissions and enhance overall patient satisfaction. You will also focus on non-clinical patient administrative work within both programs. In this role, you will serve as the primary caregiver responsible for reviewing charts, discussing high-risk cases with MDs, conducting patient outreach and managing the EON database. You will assist in risk mitigation, support patient capture and encourage patients to utilize Cleveland Clinic for their Lung Nodule and Lung Cancer Screening services, while collaborating with a multidisciplinary care team across the continuum of care to support high-risk patients.

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 (Inpatient or ambulatory).

Nice To Haves

• Bachelor's of Science in Nursing (BSN).
• Specialty certification.
• Knowledge of EMR software and EPIC.
• Pulmonary experience.

Responsibilities

• Identify patients in the specialty care practice who require ongoing care coordination for their condition.
• Outline the nature and duration of involvement needed by the specialty care team and coordinator; identify the primary care team involved.
• Utilize assessment skills and risk tools to determine actual or potential care needs; conduct comprehensive clinical assessments covering medical, behavioral, pharmacy, social, and end-of-life needs.
• Conduct targeted outreach to high-risk patients (e.g., chronic illness, limited social support, frequent ED visits, readmissions, surgical episodes) to ensure timely and efficient care delivery.
• Use technological tools (registries, patient lists, care team tab, etc.) to manage patient populations and monitor compliance with the plan of care.
• Inform and educate patients and families about care coordination and disease management; assess health literacy, knowledge, and readiness to change using teach-back methods.
• Coach patients and families on self-management support, including setting short- and long-term goals and providing education on managing specialty or surgical conditions across the continuum (preoperative, perioperative, postoperative, recovery).
• Collaborate with the interdisciplinary team to develop care goals, plan interventions, and perform reassessments; update care plans based on patient progress.
• Ensure care gaps are closed for chronic diseases, specialty conditions, and surgical episodes.
• Serve as the primary patient contact and coordinate care team members to facilitate access to services.
• Act as a liaison between patients, families, and healthcare providers; advocate for patients and resolve concerns.
• Assist in managing care transitions across settings by ensuring effective communication, identifying barriers, and facilitating solutions.

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree