Company: Cleveland Clinic
Location: Vero Beach
Posted on: May 13, 2022
- Job Profile Summary: 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
- 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
- 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
- Other duties as assigned Education:
- Graduate from an accredited school of professional
- BSN preferred Languages:
- N/A Certifications:
- Current state licensure as a Registered Nurse (RN)
- Specialty certification preferred
- Basic Cardiac Life Support (BLS) required Work Experience:
- Three to five years of nursing experience required Physical
- Requires full range of motion, manual and finger dexterity and
- Requires corrected hearing and vision to normal range
- May requires some exposure to communicable diseases or bodily
- 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
- Follows standard precautions using personal protective
equipment as required.
Keywords: Cleveland Clinic, Palm Bay , CARE COORDINATOR, Other , Vero Beach, Florida
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