RN Heart Failure Chronic Care Management Coordinator

GENERAL SUMMARY:

Responsible for the provision and oversight of professional nursing care and medical care prescribed by the Licensed Healthcare Provider (Physician, APRN, or PA). Has oversight of the Compass Rose website monitoring of enrolled Heart Failure patients. Works side by side with our Heart Failure Team in our ambulatory clinic. Assists in facilitating care coordination of patients to ensure positive outcomes and an effective overall plan of care in a professional, confidential, and caring manner. Involved in clinical activities working closely with providers, hospital and clinic staff. Connects patient/family with resources for education, support and clinical needs throughout their course of treatment.

Accountable for having knowledge of and complying with the Nebraska Nurse Practice Act and other relevant State Nurse Practice Acts, any applicable licensure/certification requirements, as well as, organizational policies and procedures.

PRINCIPAL JOB FUNCTIONS

• *Commits to the mission, vision, beliefs and consistently demonstrates our 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 social-economical assessment of referred patients and navigates care between physicians and diagnostic services.
• *Educates patient and family about tests/procedures, results, medications, nutrition and other health related issues.
• *Performs nursing care that requires professional knowledge and judgement for assigned providers, patient follow up, patient teaching and test result communication.
• *Triages and responds to calls from patients, pharmacies, hospitals, nursing homes, and other medical offices by use of telephone and computer, in a timely manner.
• *Prepares Electronic Health Record (EHR) for patient visit, ensuring all necessary information is in the chart prior to appointment for multi-specialty providers, as well as, documenting patient interactions, orders, results, patient questions/concerns and medication changes, in a timely manner.
• *Responds appropriately to urgent/emergent situations and documents as necessary.
• *Assists with rooming; including vital signs, patient history, preparing patient for examination/procedures, performing EKG, as well as, keeping rooms stocked, clean and ready for use.
• *Provides effective follow-up with program-specific patients per mandatory registry guidelines.
• Maintains communication with device representatives as applicable to program.
• Actively engages with marketing to enhance referrals and provide community education.
• *Complies with HIPAA and maintains confidentiality in matters related to patient, family, staff, and providers.
• *Maintains compliance with OSHA and safety plan.
• Notifies direct supervisor of problems/incidents related to staff or patients in a timely manner.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Participates in meetings, committees and department projects as assigned.
• Performs other related projects and duties as assigned.

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

• Coordinates bi-weekly and as needed patient case reviews with our Heart Failure Team.
• Coordinates/collaborates appropriate scheduling and communication with the Heart Failure scheduling team.
• Provides updates and communications with Heart Failure team on potential high risk heart failure re-admissions.
• Triaging of calls with our Heart Failure patients.
• Able to fill in as back up in the absence of the clinic RN’s

(Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

EDUCATION AND EXPERIENCE:

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