RN Care Coordinator Nephrology and Hypertension
Company: Cleveland Clinic
Posted on: November 22, 2021
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.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
- Serves as primary patient contact for team related to
condition/surgical episode and facilitates access to
- 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
- In home care only, this role oversees and directs clinical
staff and a team of LPNs to ensure patients receive appropriate
- 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 Life Support (BLS) through American Heart Association
- 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.Complexity of Work:
- Requires critical thinking skills, decisive judgment and the
ability to work with minimal supervision.
- Must be able to work in a stressful environment and take
appropriate action.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 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 employees and applicants for employment
in our tobacco free and drug free environment. All offers of
employment are followed by testing for controlled substance and
nicotine. Job offers will be rescinded for candidates for
employment who test positive for nicotine. Candidates for
employment who are impacted by Cleveland Clinic Health System's
Smoking Policy will be permitted to reapply for open positions
after 90 days.
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
Cleveland Clinic Health System is pleased to be an equal employment
employer: Women / Minorities / Veterans / Individuals with
Schedule: Full Time
Keywords: Cleveland Clinic, Cleveland , RN Care Coordinator Nephrology and Hypertension, Healthcare , Avon, Ohio
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