Heart Failure Coordinator

Responsibilities

• Care coordination for patients with heart failure across inpatient, outpatient, and post-discharge settings.
• Individualized education for patients and caregivers on heart failure diagnosis, symptom recognition, daily weights, medication adherence, sodium and fluid management, activity, and seeking medical attention.
• Completion and reinforcement of discharge planning, including medication reconciliation, follow-up appointment coordination, barrier assessment, and early post-discharge outreach.
• Monitoring clinical status through patient calls, symptom review, weight and vital sign trends, laboratory results, and remote monitoring or implantable device data.
• Supporting implementation and coordination of guideline-directed medical therapy, diagnostic testing, procedures, prior authorizations, and specialty referrals.
• Collaboration with physicians, advanced practice providers, primary care, pharmacy, social work, rehabilitation, home health, and community resources to address clinical, psychosocial, financial, and access barriers to care.
• Documentation of assessments, interventions, outcomes, and care plans in the medical record and applicable program databases.
• Tracking quality and program metrics such as readmissions, follow-up compliance, patient education completion, and heart failure performance measures.
• Participation in quality improvement and certification readiness activities.
• Serving as a clinical resource for staff and patients regarding heart failure best practices, self-management support, and evidence-based care pathways.
• Performing clinic-based nursing support as needed, including rooming patients, obtaining ECGs, coordinating labs, and assisting with device interrogation and monitoring workflows within scope of practice.

Qualifications

• Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred.
• Minimum of 3 years of RN clinical experience required; cardiology, heart failure, ICU, case management, care coordination, or chronic disease management experience preferred.
• Experience with patient education, discharge planning, remote monitoring, and interdisciplinary care coordination preferred.
• Current Registered Nurse (RN) license in the applicable state or compact state required.
• Basic Life Support (BLS) required; Advanced Cardiac Life Support (ACLS) preferred or required based on practice setting.
• Heart failure, cardiac, or case management certification preferred when applicable.