Care Coordinator - Transitional Care

## 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 - Transitional Care ### Location Stuart ### Facility Stuart Family Health Center ### Department Treasure Coast Integrated Hlth-Finance ### Job Code 000281 ### Shift Days ### Schedule 8:00am-5:00pm ### Job Summary ### Job Details Join the Cleveland Clinic team at Stuart Family Health Center, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, 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. Stuart Family Health Center is looking to add a Care Coordinator to the team who will support Transitional Care. As a Care Coordinator in this role, 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 follow up with recently discharged patients and follow their status for up to 30 days. Ultimately, your efforts will improve care for patients at home and reduce readmission. 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 provi…