Care Navigator

• Strengthen connections between Cleveland Clinic providers and primary care practices across the network
• Provide resources and support to promote coordinated, high-quality care
• Support utilization of Cleveland Clinic network providers and use the EMR for timely communication and care coordination
• Partner with patients, care partners, and primary care practices to support positive outcomes
• Build practice capacity for performance improvement initiatives and advance improvements in care delivery
• Serve as subject matter expert for the Navigation team
• Implement processes to guide patients to appropriate resources and support services
• Identify, evaluate, and resolve patient concerns
• Participate in multidisciplinary team projects
• Maintain departmental workflow and communications with internal and external stakeholders
• Develop communication standards and relationships with internal providers across the Cleveland Clinic network
• Complete data tracking and collection to identify statistics, opportunities, and trends
• Review, facilitate, and complete care gap closures for assigned patient populations
• Assess and provide feedback to practices regarding organizational, clinical, and business functions
• Use practice-level and physician data to drive change for value-based operations
• Coordinate and implement distribution of new clinical functionality practices
• Travel to provider offices and schedule group user training when necessary
• Document and diagram existing workflows; identify improvement opportunities and design and implement improvements with practice and Navigation Leadership teams
• Train practice staff to use data effectively for performance improvement
• Promote best-practice sharing related to performance measures
• Build team orientation and promote effective communication among practice staff
• Create a practice culture receptive to change
• Perform other duties as assigned

Population Health Navigator III – Post-Acute Care

• Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education and awareness opportunities
• Build relationships and drive appropriate and dignified hospice care for patients across physicians, providers, and hospitals
• Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources
• Serve as a hospice clinical consultant and educator, extending hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB
• Engage patients and providers to build clinical patient profiles and clinical-admission assessments
• Identify decline patterns, including frequent hospitalizations and functional deterioration
• Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
• Identify attending and consulting providers associated with referred patients
• Provide patient assessment, eligibility, and discharge education and awareness
• Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams
• Initiate and maintain care team workflows for patient information, clinical assessment and documentation, consultation, education planning and delivery, and meetings
• Identify trends, needs, and partnership opportunities for earlier hospice engagement
• Foster relationships with external care teams to improve patient outcomes and end-of-life satisfaction
• Communicate with hospital leadership and care coordination teams
• Organize, track, and prioritize high-value patient comprehensive reviews
• Meet productivity requirements, including timely medical-record review and hospital/provider consultation and education
• Promote a collaborative, team-focused environment
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization in hospitals, community, and partner interactions
• Collaborate with internal hospice departments and leadership teams
• Perform other duties as assigned

Care Navigator jobs in Ohio

Population Health Navigator III – Post-Acute Care

Transitional Care Navigator