329619   At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.   We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.  

Job Title

Care Coordinator - Chronic Care

Location

Stuart

Facility

Martin Health North

Department

Treasure Coast Integrated Hlth-Finance

Job Code

000281

Shift

Days

Schedule

8:00am-5:00pm

Job Summary

 

Job Details

  Join Cleveland Clinic’s Martin North Hospital where research and surgery are advanced, technology is leading-edge, patient care is world-class, and caregivers are family. This downtown Stuart hospital provides top-quality patient care to the communities in and around Martin County on the beautiful St. Lucie River. The caregivers at Martin North Hospital have made it an excellent medical facility and a home away from home. As a Care Coordinator, you will work collaboratively with multidisciplinary caregivers across the continuum of care to provide coordination of care and disease management longitudinally to patients with chronic condition(s). You will work to ensure patient concerns are appropriately triaged to facilitate timely resolution and provider involvement when necessary. Ultimately, your efforts will focus on enhancing treatment outcomes and decreasing future Emergency Department visits for your patients. On this team, you will learn something new every day, grow in your field, and gain access to numerous professional development resources. A caregiver in this position works days from 8:00AM – 5:00PM.   After the on-site training period, this caregiver will work remotely. Living within two hours of Martin North Hospital is required. A caregiver who excels in this role will:

• Work collaboratively with a multidisciplinary care team across the continuum of care for high-risk patients to develop goals, plan interventions and maximize patient outcomes.

• Provide care and disease management coordination.

• Identify patients in the specialty care practice that have ongoing coordination needs and conduct targeted outreach.

• Outline the nature and duration of involvement needed by the specialty care team and specialty care coordinator and identify the primary care team involved.

• Utilize assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.

• Utilize technological tools (registries, patient lists, care team tab, etc.) to manage populations.

• Conduct comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.

• Inform and work with patients and their families regarding coordination of their care, provide education and coaching, monitor patient compliance with their care plan, perform reassessments regarding patient progress toward goals and update plan of care.

• Serve as a liaison and advocate for patients and families.

• Assist in managing transitions of care across care settings, ensuring optimal communication and planning.

• Identify barriers, facilitate solutions and connect others to community resources.

• 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.

• Coach patient and family on self-management support.

• Educate about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks.

• Educate and connect to other care providers and community resources to enhance care.

Minimum qualifications for the ideal future caregiver include:

• 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

Preferred qualifications for the ideal future caregiver include:

• Bachelor’s of Science in Nursing (BSN)

• Four to five years of bedside nursing experience

• Nursing experience in the ICU

• EPIC experience

• Specialty certification

• Fluent in Spanish

  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. 

  The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.   Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.   Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.   Please review the Equal Employment Opportunity poster.   Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities