PRN RN Care Coordinator

Cleveland Clinic

1d•Remote

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 Care Coordinator, you will work collaboratively with multidisciplinary team staff across the continuum of care for high-risk patients. You will focus on patient outreach and ensuring they receive the assistance and treatment they need to promote wellness and optimal outcomes. In this position, you not only have the chance to make a meaningful difference in your community but also the opportunity to develop an exciting career in healthcare. This is a regular PRN position working remotely Monday through Friday between 8:00 a.m. -- 5:00 p.m. with the option to work either four- or eight-hour shifts various days a week.

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
Adult care or med/surg background
Recent clinical experience working in a med surg, ambulatory, inpatient or pulmonary setting

Responsibilities

Identify which patients have ongoing care coordination needs and outline the nature and duration of involvement needed by the specialty care team and specialty care coordinator.
Conduct 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.
Utilize technological tools (registries, patient lists, care team tab, etc.) to manage populations and conduct comprehensive clinical assessments, including disease-specific, age-specific, medical, behavioral pharmacy, social and end of life needs of each patient.
Inform the patient and family regarding coordination of their care, share information with the healthcare team and collaborate with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
Perform reassessments of patient progress toward goals and update plan of care as appropriate.
Ensure care gaps are closed around specialty disease/chronic disease/surgical episodes.
Serve as primary patient contact for team and the liaison between patients, families, physicians and clinical staff by advocating for patients and families.
Assist in managing transitions of care across settings, ensuring optimal communication and planning, and identifying barriers to receiving care and facilitating solutions.
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.
Work with the patient and family to assess current knowledge, health literacy and readiness to change, utilizing teaching back to assess level of knowledge.
Coach patients 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.