- Understands readmission opportunities within the community and individual patient needs.
- Has strong collaborative skills within a multidisciplinary team.
- Can work as a team member to plan, develop, strategize, market and implement community health and education programs.
- Has analytical skills and subject matter expertise related to disease processes and management of disease from the patient's perspective.
- 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.
- Other duties as assigned.
- Graduate from an accredited school of professional nursing.
- BSN preferred
- Current state licensure as a Registered Nurse (RN).
- Specialty certification preferred.
- Basic Cardiac Life Support (BLS) required
- Any registered nurse or advanced practice nurse must obtain a cancer specific certification or demonstrate ongoing qualifying education within the timeframe of the facilities accreditation cycle, if they work in medical oncology, radiation oncology, cancer center or cancer clinic and/or administer chemotherapy within an accredited Cleveland Clinic facility.
- Three to five years of nursing experience required
- 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.
- Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects.
- Follows Standard Precautions using personal protective equipment as required for procedures.
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rn care coordinator - Davie, FL , USA, United States - Cleveland Clinic
Description
Join the Cleveland Clinic Weston team, where you will work alongside passionate caregivers and provide patient-first healthcare. 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 Care Coordinator, you will work collaboratively with multidisciplinary care team staff across the continuum of care for high-risk patients.
The Care Coordinator provides coordination of care and disease management longitudinally to patients with chronic condition(s) or episodic care of a surgical population and focuses efforts on patient outreach and coordination of care for a panel of patients to achieve optimal outcomes and promote wellness, decreasing preventable ED visits and readmissions while improving patient satisfaction.
The ideal future caregiver is someone who:
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.
Job Responsibilities:
Education:
Certifications:
Work Experience:
Physical Requirements:
(1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.
Personal Protective Equipment:
Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic.
Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.
