Cleveland Clinic

Compensation

Full Description

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 Transitional Care RN Care Coordinator Location Cleveland Facility Remote Location Department Express Care-Integrated Hospital Care Institute Job Code T99128 Shift Days Schedule 8:00am-5:00pm Job Summary Job Details This remote role is responsible for conducting Transitional Care Management (TCM) calls to patients within 24–48 hours after hospital discharge, ensuring they understand their medications, discharge instructions, and have support for follow-up care or scheduling needs. Each team member is aligned with a specific primary care office, managing post-discharge calls and addressing patient concerns specific to that location. In addition to TCM responsibilities, they support the Breathe Well program for pediatric asthma patients by reviewing emergency department discharges that meet certain criteria. They follow up with these patients to confirm access to medications, assess asthma control, ensure asthma tests are being completed, and provide education as needed. The role also involves collaboration with pediatric subspecialties to identify common barriers and questions from patients and families, helping to improve continuity of care. We’re seeking a candidate with a minimum of 3 years of experience—preferably in inpatient, pediatric (clinical or non-clinical), or ambulatory care settings—who demonstrates strong critical thinking skills and the ability to work independently while also collaborating effectively as part of a team. Experience working with children and families is strongly preferred, as it requires empathy, patience, and communication that can be difficult to train. The ideal candidate is proactive in seeking out resources, supports team coverage when needed, and communicates clearly and professionally. Familiarity with EPIC is required to support patient interactions and documentation efficiently. A caregiver in this position works 8:00am—5:00pm. 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. Conduct comprehensive clinical assessments that include disease/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. 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 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 Preferred qualifications for the ideal future caregiver include: Bachelor’s of Science in Nursing (BSN) Specialty certification 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: 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 tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year. 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 We know that fully supporting our caregivers is what creates the best outcomes for our patients. Our outstanding, comprehensive offerings are an investment in your health, well-being and future. What began in Cleveland in 1921 has grown to include locations throughout, the U.S. and even other countries. For you, that means more opportunities to learn, grow and serve patients — while finding caring, thriving communities both at work and at home. Cleveland Clinic is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Headquartered in Cleveland, Ohio, it was founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation. Cleveland Clinic has pioneered many medical breakthroughs, including coronary artery bypass surgery and the first face transplant in the United States. U.S. News & World Report consistently names Cleveland Clinic as one of the nation’s best hospitals in its annual “America’s Best Hospitals” survey. Among Cleveland Clinic’s 70,800 employees worldwide represent 140 medical specialties and subspecialties. Cleveland Clinic is a 6,500-bed health system that includes a 173-acre main campus near downtown Cleveland, 19 hospitals, more than 220 outpatient facilities, and locations in southeast Florida; Las Vegas, Nevada; Toronto, Canada; Abu Dhabi, UAE; and London, England.