RN Care Coordinator – Gastroenterology Outpatient Clinic

Works collaboratively with multidisciplinary care team staff across the continuum of care for high risk patients. Provides coordination of care and disease management longitudinally to patients with chronic condition(s) or episodic care of a surgical population. 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.

Join Cleveland Clinic Weston Hospitals team of caregivers that remain on the leading edge of technology and education all while consistently providing patient-centered healthcare. As part of Cleveland Clinics Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale metro area and Florida. Here, 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 Registered Nurse (RN) Care Coordinator, you will work collaboratively with multidisciplinary care team staff across the continuum of care for high-risk patients. The RN 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.

A caregiver in the position works Monday-Friday, from 8am – 5pm. No weekends or major holidays.

Minimum qualifications for a caregiver in this role are:

Three to five years of nursing experience.

Graduate from an accredited school of professional nursing.

Current state licensure as a Registered Nurse (RN).

Basic Cardiac Life Support (BLS) through the American Heart Association.

Preferred qualifications for the ideal caregiver are:

Experience in Gastroenterology.

Case manager/Care coordination experience.

BSN Degree.

Specialty national certification.

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Not only are we one of the best places to receive care, but were one of the best places to work in healthcare, too. In fact, were consistently ranked among the top workplaces in the country. One way well reward your contributions when you join our team is with our My Pay Benefits package that invests in your health, well-being and future. Click here to learn more: Benefits – Cleveland Clinic Careers (https://jobs.clevelandclinic.org/benefits-2/)

Job Responsibilities:

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.

Education:

Graduate from an accredited school of professional nursing.

BSN preferred

Certifications:

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.

Work Experience:

Three to five years of nursing experience required

Physical Requirements:

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. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (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:

Follows Standard Precautions using personal protective equipment as required for procedures.

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.

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities