Join Cleveland Clinic Fairview Hospital and experience world-class healthcare at its best. Cleveland Clinic Fairview Hospital is a proud Magnet Hospital awarded by the American Nurses Credentialing Center, the highest honor an organization can receive for professional nursing practice. On our team, you will provide stellar care at one of the top healthcare organizations in the nation. As Care Coordinator for the Medical and Radiology Oncology Units, you will work collaboratively with multidisciplinary team staff across the continuum of care for high-risk patients. You will focus on patient outreach and ensuring they receive the assistance and treatment they need to promote wellness and optimal outcomes. In this position, you not only have the chance to make a meaningful difference in your community but also the opportunity to develop an exciting career in healthcare. **A caregiver in this position works days from 8:00AM - 4:30PM, with three weekly scheduled days during initial hire period for training.** A caregiver who excels in this role will: + Identify which patients have ongoing care coordination needs and outline the nature and duration of involvement needed by the specialty care team and specialty care coordinator. + Conduct 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. + Utilize technological tools (registries, patient lists, care team tab, etc.) to manage populations and conduct comprehensive clinical assessments, including disease-specific, age-specific, medical, behavioral pharmacy, social and end of life needs of each patient. + Inform the patient and family regarding coordination of their care, share information with the healthcare team and collaborate with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes. + Perform reassessments of patient progress toward goals and update plan of care as appropriate. + Ensure care gaps are closed around specialty disease/chronic disease/surgical episodes. + Serve as primary patient contact for team and the liaison between patients, families, physicians and clinical staff by advocating for patients and families. + Assist in managing transitions of care across settings, ensuring optimal communication and planning, and identify barriers to receiving care and facilitates solutions. + 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. + Work with the patient and family to assess current knowledge, health literacy and readiness to change, utilizing teach back to assess level of knowledge. + Coach patients and family on self-management support; including setting long- and short-term goals. + Educate about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks. Minimum qualifications for the ideal future caregiver include: + Graduate form an accredited school of Professional Nursing + Current state licensure as a Registered Nurse (RN) + Basic Life Support (BLS) through American Heart Association (AHA) + Three to five years of nursing experience, notably in Oncology or Ambulatory Preferred qualifications for the ideal future caregiver include: + Bachelor's of Science in Nursing (BSN) Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we're dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/ **Physical Requirements:** + Full range of motion, manual and finger dexterity and eye-hand coordination + Corrected hearing and vision to normal range + 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 to move objects **Personal Protective Equipment:** + Follow Standard Precautions using personal protective equipment as required for procedures Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process. Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities