RN Care Coordinator - Neurology

Cleveland Clinic•Great Barrington, MA

About The Position

The RN Care Coordinator works collaboratively with multidisciplinary team members across the continuum of care for high-risk neurology patients. The role focuses on patient outreach and ensuring patients receive the assistance and treatment they need to promote wellness and optimal outcomes. The position is part time, with caregivers working 8:00 a.m.–4:30 p.m. or 8:30 a.m.–5:00 p.m., two days one week and three days the next. Workdays are not fixed, so schedule flexibility is required. There are no weekend, holiday, or on-call requirements. The coordinator identifies patients needing ongoing care coordination, conducts targeted outreach, assesses patients’ clinical and social needs, and partners with patients, families, and interdisciplinary care teams to develop and update care plans. The role also supports transitions between care settings, closes care gaps, follows disease-specific care paths, and educates and coaches patients and families on condition management and self-management.

Requirements

Graduate of 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 the American Red Cross.
Three to five years of nursing experience.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Direct patient care experience.

Responsibilities

Identify patients with ongoing care coordination needs and determine the nature and duration of involvement needed from the specialty care team and coordinator.
Conduct targeted outreach to a defined panel of high-risk patients to support timely, efficient care across the continuum.
Use technological tools, including registries, patient lists, and the care team tab, to manage populations and conduct comprehensive clinical assessments of disease-specific, age-specific, medical, behavioral, pharmacy, social, and end-of-life needs.
Inform patients and families about care coordination, share information with the healthcare team, and collaborate with the interdisciplinary team to develop goals and interventions that maximize patient outcomes.
Reassess patient progress toward goals and update plans of care as appropriate.
Ensure care gaps are closed around specialty disease, chronic disease, and surgical episodes.
Serve as the primary patient contact for the team and as a liaison among patients, families, physicians, and clinical staff, advocating for patients and families.
Assist with transitions of care across settings by supporting communication and planning, identifying barriers to care, and facilitating solutions.
Partner with other care coordinator teams, including primary and transitional care social work, rehabilitation, pharmacy, and palliative care.
Define and ensure compliance with disease-specific care paths for specialty care or chronic disease.
Assess patients’ and families’ current knowledge, health literacy, and readiness to change, using teach-back to assess understanding.
Coach patients and families in self-management support, including setting long- and short-term goals.
Educate patients and families about specialty or surgical condition management, including preoperative, perioperative, postoperative, recovery, prevention, and health maintenance.