Clinical Nurse Navigator - CHF - Portage

About the role

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.

Primary Location: United States-Ohio-Ravenna; Work Locations: 6847 N Chestnut St.

Responsibilities

• 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.
• Works 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 illnesses.
• Coordinates discharge medication process, pharmacy location, and ensures patient has medications for discharge at applicable facilities.
• Works with the hospital care transitions team to 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 manages the care of heart failure patients, triages calls, and escalates high risk patients using remote assessment skills and nursing expertise with provider oversight.
• Collaborates with Advanced Heart Failure cardiologists on patients with chronic heart failure and advanced heart failure, specifically partnering on early referrals for evaluation for advanced heart failure therapies (LVAD and transplant).
• Exhibits 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.
• Provides 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.
• Is 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.
• Refers to department‑provided documentation for specific duties and responsibilities during orientation.
• Abides by all requirements to safely and securely maintain Protected Health Information (PHI) for patients.
• Completes annual training and adheres to the UH Code of Conduct and UH policies and procedures regarding appropriate use of PHI in the workplace.

Qualifications

• Education: Bachelor's Degree in Nursing (BSN) – Required.
• Work Experience: 3+ years in clinical medicine/RN – Required; Coronary Care and telemetry experience strongly preferred.
• Licenses and Certifications: Registered Nurse (RN), Ohio and/or Multi State Compact License – Required upon hire.

Skills

• 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.