RN Coordinator - Heart Failure Case Manager SHEA

Responsibilities

• Collaborates with patients/caregivers to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum.
• Supports and coordinates with patient, family and inpatient multi-disciplinary team members providing appropriate post-acute level pathway, screenings, assessments, care coordination, discharge planning, advance directives, early & post-acute interventions, readmission risk, barriers to care outpatient including home support, medication management, expectation, etc., post-acute discharge plan, after-care plan of the assigned evidenced based care management pathway to promote a smooth transition primarily from a hospital discharge to a less acute or outpatient setting.
• Provides support and guidance to patients and their caregivers regarding medication reconciliation, assessment of post-discharge needs, self-management support, follow-up care post discharge, supportive care, end-of-life decisions, community resources, and long-term planning needs.
• Assures PCP is aware of patient’s admission
• Reviews discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific “red flags” of complications
• Conducts effective post-hospitalization home visits, telephonic monitoring, or both depending on the risk for readmission.
• Provides effective communication of clinical information and plan of care between the Hospitalist, Emergency Room Physician, Specialists, PCP and community referrals; as well as other key healthcare providers involved in the case.
• Facilitates a smooth and timely transition from acute care to the post acute setting and PCP
• Captures and maintains clear and professional clinical documentation in software data base for cases followed under transition and for case assignment.
• Coordinates follow-up care with PCP/ Specialists/Community providers regarding outpatient follow-up appointment and plan of care.
• Communicates key information regarding inpatient stay and discharge plans to patient’s PCP and healthcare team.
• Ensures safe transmission of personal health information.
• Ensures post-acute telephone, home visits are conducted and after care issues are followed-up as determined by case needs to assess self-care monitoring and system management.
• Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.

Qualifications

• Bachelor's Degree BSN or equivalent Bachelor of Science - Required
• 3 years RN clinical experience with heart failure or Pulmonary Artery Hypertension - Required
• Registered Nurse (RN) State And/Or Compact State Licensure RN (AZ or State Compact Licensure in good standing) - Required
• BSN and/or MSN, Certification in Case Management - Preferred