A Brief Overview The Heart Failure Navigator is responsible for the care coordination and implementation of best practice elements across the health care continuum. Works in partnership with patients, care givers, physicians, physician practices, hospital personnel, and post-acute providers to collaborate, educate and implement strategies to improve the care of heart failure patients.
Implements best practice elements related to heart failure and chronic illness care across the health care continuum to ensure high quality coordinated care of patients. Rounds on/reviews assigned patients regularly and evaluates patient progress with plan of care. Communicates plan of care to patient and family and solicits concerns, questions, and issues for resolution.
Work as an interdisciplinary care team member to manage the care journey and anticipate care support and education needs of patients diagnosed with heart failure and other chronic illness’ Coordinate discharge medication process, pharmacy location, and insure patient has medications for discharge at applicable facilities Working with the hospital care transitions team, perform transition of care management to CHF patients after discharge from the hospital, successfully bridging the transition from hospital to outpatient care and preventing readmissions.
Remotely manage the care of heart failure patients, triage calls, and escalate high risk patients using remote assessment skills and nursing expertise with provider oversight. Collaborate with Advanced Heart Failure cardiologists on patients with chronic heart failure and advanced heart failure, specifically partner on early referrals for evaluation for advanced heart failure therapies (LVAD and transplant). Additional Responsibilities Exhibit an in-depth knowledge of disease processes, pharmacology, and current guidelines to develop comprehensive care support for patients and promote successful outcomes.
Exhibits strong communication skills using empathy and social intelligence to evaluate patient needs and promote patient engagement and self-care. Community resource referral, patient education, and navigation at the entry point and across the continuum of care. Actively participates in the process for operational improvement and quality improvement.
Involved in learning and self-improvement. Provides leadership through communication, education and management. Provides advocacy for the patient and family.
Initiates and maintains positive relationships with coworkers and physicians. Demonstrates commitment to the mission, vision and values of UH. Performs other duties as assigned.
Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients.
Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Education (BSN) Bachelor's Degree in Nursing (Required) Work Experience 3+ years in clinical medicine/ RN (Required) and Coronary Care and telemetry experience strongly preferred Knowledge, Skills, & Abilities Thorough knowledge of nursing process and practice (Required proficiency) Outstanding written and verbal communication skills.
(Required proficiency) Comprehensive understanding of local medical systems and resources (Required proficiency) Understands multiple computer systems including, but not limited to: UHCare EMR, Sorian Scheduling. (Required proficiency) Management and handling of patient records. (Required proficiency) Excellent time management skills and proactive approach to the needs of customers.
(Required proficiency) Licenses and Certifications Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) Physical Demands Standing Frequently Walking Frequently Sitting Rarely Lifting Frequently 50 lbs Carrying Frequently 50 lbs Pushing Frequently 50 lbs Pulling Frequently 50 lbs Climbing Occasionally 50 lbs Balancing Occasionally Stooping Frequently Kneeling Frequently Crouching Frequently Crawling Occasionally Reaching Frequently Handling Frequently Grasping Frequently Feeling Constantly Talking Constantly Hearing Constantly Repetitive Motions Constantly Eye/Hand/Foot Coordination Constantly Travel Requirements 10%