Cardiology Heart Failure Nurse Navigator, Full Time Days, 8a - 4p, Atlantic Health, Morristown Medical Center
The Heart Failure Navigator is a specialized clinical professional responsible for coordinating and optimizing care for patients with heart failure across the continuum—from inpatient care through discharge and outpatient management. The role focuses on improving clinical outcomes, reducing readmissions, achieving LOS targets, and ensuring adherence to evidence-based heart failure guidelines.
The Heart Failure Navigator facilitates seamless transitions across the continuum of care, reduces readmissions, improves compliance with guideline-directed therapy, and enhances the patient experience through education and coordinated follow-up.
Patient Care Coordination
- Identify and follows heart failure patients during inpatient admission and outpatient encounters
- Coordinate multidisciplinary care (cardiology, primary care, nursing, case management, pharmacy, rehab)
- Facilitate smooth transitions of care from hospital to home, rehab, or outpatient follow-up
- Ensures post hospital discharge appointments are in place prior to discharge
Clinical Management & Monitoring
- Ensure adherence to evidence-based clinical guidelines (e.g., GDMT for heart failure)
- Monitor patients for clinical deterioration and intervene early
- Collaborate with providers to optimize medical therapy
- Review labs, imaging, and diagnostics relevant to heart failure management
Patient & Family Education
- Provide education on:
- Disease process and symptom recognition
- Medication adherence
- Dietary restrictions (e.g., low sodium)
- Daily weight monitoring and self-management
- Reinforce discharge instructions and self-care plans
Readmission Reduction & Outcomes Management
- Develop and implement strategies to reduce 30-day readmissions
- Conduct post-discharge follow-up calls or visits
- Track and report quality metrics (LOS, readmissions, mortality, compliance)
- Monitors LOS and develops strategies to help achieve targets
Care Transition & Discharge Planning
- Ensure timely follow-up appointments (cardiology and primary care)
- Coordinate discharge needs (home care, equipment, medications)
- Address barriers to care such as transportation or medication access
Quality Improvement & Program Development
- Participate in heart failure program development and accreditation initiatives
- Analyze data to identify trends and opportunities for improvement
- Support regulatory compliance (e.g., Joint Commission, CMS metrics)
Documentation & Reporting
- Maintain accurate documentation in the electronic medical record
- Track patient outcomes and registry data
- Prepare reports for leadership and quality committees
Required:
1. Bachelor's in Nursing or related field.
2. Valid State or national Nursing License.
3. 2 years of experience in Acute Care or relevant area.
Preferred:
1. Heart Failure certification (e.g., CHFN) preferred