Oversees the coordination of care for patients hospitalized with Congestive Heart Failure and Myocardial Infarction. Provides comprehensive education regarding the disease process using multiple modalities to ensure understanding. Serves in an expanded nursing role to collaborate with the Care Team to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Integrates modified evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Works closely with inpatient and ambulatory care management to offer seamless transitions of care.

Responsibilities:

• Monitor patient progress during acute care setting to promote early interventions to reduce length of stay and minimize readmission. Provides individualized education related to specific disease process, associated treatment modality, and agreed plan of care for patient and family. Initiates goals of care conversation with patient and family.
• Provide safe transitions throughout the continuum of care by collaborating with the care team, patient, and family to develop and manage the plan of care, while promoting patient independence and self-management.
• Demonstrate the ability to negotiate and influence individual and group decision- making.
• Adapt to a fluid, dynamic and rapidly changing environment.
• Demonstrate leadership qualities in the areas of time management, problem solving, decision making, prioritization, delegation, organization, skilled written/verbal communication and listening skills.
• Monitors laboratory results, diagnostic tests, utilization patterns and other metrics in collaboration with the interdisciplinary team to monitor quality and efficiency results for assigned population.
• Provides up-to-date coordinated patient centered care to the multidisciplinary care team.
• Collaborates with Inpatient/Outpatient Care Management staff to facilitate smooth transitions across the healthcare continuum.
• Discharge planning confirmation (inpatient CM will continue usual coordination, while HF navigator confirms best plan for the patient), disease process education, medication reconciliation prior to discharge, ensure patient has all prescriptions to include elimination barriers to obtaining, and set follow up appointment.
• Other Duties.

Credentials

• Required Registered Nurse
• Basic Life Support

Education

• Required Associate's Degree
• Bachelor's Degree in Nursing Preferred.

Required Experience

• 3 year/years of Relevant Work Experience