Clinical Nurse Navigator - CHF - Portage

The Heart Failure Navigator is responsible for the care coordination and implementation of best practice elements across the health care continuum. Works in partnership with patients, care givers, physicians, physician practices, hospital personnel, and post-acute providers to collaborate, educate and implement strategies to improve the care of heart failure patients.

• Implements best practice elements related to heart failure and chronic illness care across the health care continuum to ensure high quality coordinated care of patients.
• Rounds on/reviews assigned patients regularly and evaluates patient progress with plan of care. Communicates plan of care to patient and family and solicits concerns, questions, and issues for resolution.
• Work as an interdisciplinary care team member to manage the care journey and anticipate care support and education needs of patients diagnosed with heart failure and other chronic illness’
• Coordinate discharge medication process, pharmacy location, and insure patient has medications for discharge at applicable facilities
• Working with the hospital care transitions team, perform transition of care management to CHF patients after discharge from the hospital, successfully bridging the transition from hospital to outpatient care and preventing readmissions.
• Remotely manage the care of heart failure patients, triage calls, and escalate high risk patients using remote assessment skills and nursing expertise with provider oversight.
• Collaborate with Advanced Heart Failure cardiologists on patients with chronic heart failure and advanced heart failure, specifically partner on early referrals for evaluation for advanced heart failure therapies (LVAD and transplant).

• Exhibit an in-depth knowledge of disease processes, pharmacology, and current guidelines to develop comprehensive care support for patients and promote successful outcomes.
• Exhibits strong communication skills using empathy and social intelligence to evaluate patient needs and promote patient engagement and self-care.
• Community resource referral, patient education, and navigation at the entry point and across the continuum of care.
• Actively participates in the process for operational improvement and quality improvement.
• Involved in learning and self-improvement.
• Provides leadership through communication, education and management.
• Provides advocacy for the patient and family.
• Initiates and maintains positive relationships with coworkers and physicians.
• Demonstrates commitment to the mission, vision and values of UH.
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.