Care Coordinator RN Nurse Navigator

About the role

As a Care Coordinator RN Nurse Navigator, you will collaborate with Emergency Department physicians and a multidisciplinary care team to coordinate care for high-risk patients across the continuum of care. In this role, you will support ED provider-led patient management by conducting patient outreach, facilitating care coordination, and providing longitudinal disease management for patients with chronic conditions or episodic healthcare needs. You will work to ensure seamless transitions of care, promote wellness, reduce preventable emergency department visits and hospital readmissions, and enhance patient satisfaction through timely communication and coordination with patients, providers, and community resources.

Responsibilities

• 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.
• Assist and support in the care coordination led by the ED provider.
• Ensure the chart contains the necessary information for the patient and is updated as needed (med lists, PCP, recent care in other hospitals, preferred pharmacies, etc.).
• Assist in real-time communication with the patient and their family when ED visits or clinical evaluations are required.
• Collaborate with local West Palm Beach Emergency Departments when patients are present for acute care, serving as the primary liaison between emergency providers and patients to ensure seamless communication and continuity of care.
• Follow-up calls on the status of a patient after being discharged from a health facility.
• Communicate with pharmacies (as needed) for prescriptions.
• Ensure diagnostic results are shared with the necessary clinical team members of the patient.
• Secure necessary follow-up appointments.
• Be available for on call at all times – relief coverage provided.

Requirements

• Graduate from an accredited school of Professional Nursing (Diploma, ADN, BSN program)
• 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

Preferred qualifications

• Bachelor’s of Science in Nursing (BSN)
• Specialty certification
• Outpatient/Hospital experience
• Emergency Department experience
• ACLS certification through the American Heart Association (AHA) or the American Red Cross
• Care coordination experience

Physical Requirements

• Requires full range of motion, manual and finger dexterity and eye-hand coordination.
• Requires corrected hearing and vision to normal range.
• May require 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.

Benefits

• Health Plan Options – You have the choice between two comprehensive Cleveland Clinic Employee Health Plan options: EHP and EHP Plus. Both plans are administered by Aetna and feature minimal copays for in-network care. Although the benefit designs of EHP and EHP Plus are identical, they differ in their provider network size, with EHP offering a narrow network and EHP Plus providing access to the wide Aetna Open Access Select network. Both plans include access to Cleveland Clinic providers. The health plan also offers Healthy Choice, a voluntary program where participants earn premium discounts for achieving wellness goals.
• Dental Care – Four plan options administered by Cigna are available.
• Vision Care – Two plan options administered by EyeMed are available.
• Flexible Spending Accounts – Healthcare and Dependent Care FSAs are available to help you pay for eligible expenses with pre-tax dollars.
• Life Insurance – Employer-paid life insurance equals 1x your annual salary with an option to purchase supplemental life insurance up to 10x your salary. You may also purchase dependent life insurance for a spouse and dependent children.
• Short- and Long-term Disability Coverage – Short-term disability is available after one continuous year of regular full-time service; long-term disability begins after 90 days.
• The Cleveland Clinic Investment Pension Plan offers eligible employees an excellent opportunity to build a retirement account for the future. It is fully funded by Cleveland Clinic and equal to 2.5% of your salary (increasing with more years of service).
• The 401(k) / 403(b) Plan also provides an important source of retirement savings. It allows participants to take responsibility for their financial future by making retirement savings a part of their normal routine while working. In addition to your contributions to the plan, Cleveland Clinic matches a portion of your contributions (50% on up to your first 6% in contributions).
• Paid Time Off (PTO) – Eligible caregivers receive Paid Time Off (PTO) that can be allotted toward vacation, holidays, sick time, etc.
• Caregiver discounts – We offer discounted rates for auto, home and pet insurance, identify theft protection and more.
• Adoption assistance – We provide financial assistance of up to $5,000/per child ($10,000 maximum lifetime benefit) for caregivers who choose to legally adopt a child.
• Employee Assistance Program – The Program provides free, confidential short-term counseling for caregivers and their families, whether for relationships or legal challenges.
• Employee Hardship Fund – This fund provides aid for caregivers experiencing unexpected financial difficulties.
• Paid maternity and parental leave – You will enjoy up to eight consecutive weeks for maternal care after the birth of your child to bond with your baby and up to four weeks for parental care.