RN-Navigator Heart Failure

Reid Health

About The Position

The Nurse Navigator – Heart Failure is responsible for the coordination of evaluation and management of heart failure patients with a primary goal of decreasing readmissions. The nurse navigator will monitor patients closely to recognize heart failure manifestations early; monitoring will be accomplished by phone and face – to – face contact with the patient. Will work with and communicate with staff from Reid Health, RHPA, and community organizations. Overview of Responsibilities Guide heart failure patients through Reid’s health care system by assisting with access issues, decreasing readmissions, coordinate and manage care, while tracking interventions, outcomes and experiences for heart failure patients. Responsible for reviewing patients for enrollment in the Heart Failure Clinic and providing continuity of care delivering a seamless, coordinated process that supports the patient’s need for education, care coordination and psychosocial super across their experience. Coordinate care through assessment, planning, implementation and the evaluation process. Develop a comprehensive care plan with patients enrolled in heart failure navigation to meet billing requirements for principal care management. Provide assessment and planning of patient’s care; establishing and maintaining a plan of care across the continuum of care in collaboration with patient, family and health team members including individualized interventions, goals, outcomes and education, and modifying or continuing plan based on the patient need. Work collaboratively with Care Coordinators, Transition Coaches, Palliative Care/Hospice Case Managers, Community Paramedicine Program, Home Health Agencies, and other physician offices to coordinate care. Provide intervention, evaluation and follow-up to include implementing nursing and medical interventions using appropriate resources, skills and knowledge; evaluating effects of care provided and identifying changes in patient needs. Collect information and report all heart failure readmissions monthly with an explanation for each readmission. Provide effective communication and documentation by communicating and documenting interventions, patient responses according to standards and referral information; utilizing recognized organization communication standard; keeping abreast of and complying with departmental and organizational changes and events; attending and participating in clinic department meetings. Collaborate and work with service line leadership to develop educational programs, formulate policies and procedures, establish goals, and engage in problem-solving activities. In conjunction with clinic leadership, provide outreach and education to both outside medical groups and patients in the community. Perform general duties to include maintain working knowledge of infection control, risk management and emergency preparedness plans; actively participate in performance improvement initiatives; demonstrate knowledge of organization and department goals, standards and operations; maintain knowledge base and respond to laws and regulations which affect practice. This list of duties and responsibilities is not intended to be all-inclusive and can be expanded to include other duties or responsibilities that management deems necessary.

Requirements

Associate of Science Degree in Nursing required
Minimum 2–3 years’ experience in nursing
Indiana Nursing Licensure
BLS

Nice To Haves

Bachelor of Science Degree in Nursing
Previous experience with cardiac patients, including heart failure patients
must demonstrate leadership qualities and ability to communicate in a team environment

Responsibilities

coordination of evaluation and management of heart failure patients with a primary goal of decreasing readmissions
monitor patients closely to recognize heart failure manifestations early
Work with and communicate with staff from Reid Health, RHPA, and community organizations
Guide heart failure patients through Reid’s health care system by assisting with access issues, decreasing readmissions, coordinate and manage care, while tracking interventions, outcomes and experiences for heart failure patients
Responsible for reviewing patients for enrollment in the Heart Failure Clinic and providing continuity of care delivering a seamless, coordinated process that supports the patient’s need for education, care coordination and psychosocial super across their experience
Coordinate care through assessment, planning, implementation and the evaluation process
Develop a comprehensive care plan with patients enrolled in heart failure navigation to meet billing requirements for principal care management
Provide assessment and planning of patient’s care; establishing and maintaining a plan of care across the continuum of care in collaboration with patient, family and health team members including individualized interventions, goals, outcomes and education, and modifying or continuing plan based on the patient need
Work collaboratively with Care Coordinators, Transition Coaches, Palliative Care/Hospice Case Managers, Community Paramedicine Program, Home Health Agencies, and other physician offices to coordinate care
Provide intervention, evaluation and follow-up to include implementing nursing and medical interventions using appropriate resources, skills and knowledge; evaluating effects of care provided and identifying changes in patient needs
Collect information and report all heart failure readmissions monthly with an explanation for each readmission
Provide effective communication and documentation by communicating and documenting interventions, patient responses according to standards and referral information; utilizing recognized organization communication standard; keeping abreast of and complying with departmental and organizational changes and events; attending and participating in clinic department meetings
Collaborate and work with service line leadership to develop educational programs, formulate policies and procedures, establish goals, and engage in problem-solving activities
In conjunction with clinic leadership, provide outreach and education to both outside medical groups and patients in the community
Perform general duties to include maintain working knowledge of infection control, risk management and emergency preparedness plans; actively participate in performance improvement initiatives; demonstrate knowledge of organization and department goals, standards and operations; maintain knowledge base and respond to laws and regulations which affect practice