RN Heart Failure Chronic Care Management Coordinator

Responsible for the provision and oversight of professional nursing care and medical care prescribed by the Licensed Healthcare Provider (Physician, APRN, or PA). Oversees the Compass Rose website monitoring of enrolled Heart Failure patients, works side‑by‑side with the Heart Failure Team in an ambulatory clinic, and facilitates care coordination to ensure positive outcomes in a professional, confidential, and caring manner.

Responsibilities

• Commits to the mission, vision, beliefs and consistently demonstrates core values.
• Collaborates with physicians from multi‑specialties in developing referrals, coordinating clinic and outpatient visits, and appropriately navigating clinical care.
• Provides procedural coordination to the applicable BH Program (LAAO, Structural Heart Program, etc.) and other related procedures or diagnostic testing.
• Receives physician referrals and efficiently compiles clinical data for presentation to a multi‑specialty physician team at scheduled program meetings.
• Performs clinical and socio‑economic assessment of referred patients and navigates care between physicians and diagnostic services.
• Educates patients and families about tests/procedures, results, medications, nutrition, and other health‑related issues.
• Delivers nursing care requiring professional knowledge and judgment for assigned providers, including patient follow‑up, teaching, and test result communication.
• Triages and responds to calls from patients, pharmacies, hospitals, nursing homes, and other medical offices via telephone and computer in a timely manner.
• Prepares the Electronic Health Record (EHR) for patient visits, ensuring all necessary information is in the chart prior to appointments and documenting interactions, orders, results, questions/concerns, and medication changes promptly.
• Responds appropriately to urgent/emergent situations and documents as necessary.
• Assists with rooming, including vital signs, patient history, preparation for examinations/procedures, performing EKG, and maintaining stocked, clean rooms ready for use.
• Provides effective follow‑up with program‑specific patients per mandatory registry guidelines, maintains communication with device representatives, and engages with marketing to enhance referrals and provide community education.
• Complies with HIPAA and maintains confidentiality for patients, families, staff, and providers.
• Maintains compliance with OSHA and safety plans; notifies supervisors of problems or incidents related to staff or patients promptly.
• Maintains professional growth through seminars, workshops, and professional affiliations; participates in meetings, committees, and department projects as assigned.
• Performs other related projects and duties as assigned.

Additional Responsibilities

• Coordinates bi‑weekly and as‑needed patient case reviews with the Heart Failure Team.
• Coordinates and collaborates on scheduling and communication with the Heart Failure scheduling team.
• Provides updates and communications to the Heart Failure team on potential high‑risk heart‑failure re‑admissions.
• Triages calls from Heart Failure patients.
• Serves as backup in the absence of clinic RNs.

Requirements

• Graduation from an accredited Registered Nursing program (BSN preferred).
• Current Registered Nurse licensure from the State of Nebraska or an approved compact state as defined by the Nebraska Nurse Practice Act.
• Minimum of three (3) years of relevant nursing experience.
• Clinic and cardiovascular nursing experience preferred.