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/