Clinical Heart Failure Program Care Coordinator

CardioOne•Londonderry, NH

4h•Onsite

About The Position

Cardiovascular Specialists of New England is seeking a highly motivated Heart Failure Program Care Coordinator to coordinate and support ongoing care for patients enrolled in its Heart Failure Program. The role serves as a central point of coordination among patients, families, cardiologists, advanced practice providers, clinical staff, hospitals, and other healthcare partners. It supports proactive heart failure management through timely follow-up, medication reconciliation, patient education, symptom and vital-sign monitoring, coordination of diagnostic testing and appointments, and identification and escalation of clinical concerns. The position focuses on improving outcomes, promoting adherence to evidence-based treatment plans, reducing avoidable hospitalizations and readmissions, and maintaining continuity of care. The coordinator works from the Londonderry, New Hampshire office and the Manchester, New Hampshire office when needed, in an outpatient cardiology environment. The role includes regular telephone, electronic, EMR-based, and in-person patient interactions, and frequent communication with patients, families, providers, hospitals, and external healthcare organizations. The position reports directly to the Clinical Nurse Manager, Lisa Goupil.

Requirements

Current BLS certification is required.
Working knowledge of cardiovascular disease, particularly heart failure, common cardiac diagnoses, medications, and treatment plans.
Ability to recognize changes in patient-reported symptoms and clinical data and escalate them appropriately.
Strong communication and patient-interaction skills, including telephone communication and patient education.
Ability to interpret clinical documentation and cardiac terminology.
Strong organizational skills and exceptional attention to detail.
Ability to manage multiple patients and follow-up activities while meeting established timelines.
Proficiency with EMR systems and care-management or remote-monitoring platforms.
Ability to work collaboratively within a multidisciplinary clinical team.
Compassionate, patient-centered approach.
Ability to maintain professional boundaries and recognize when clinical concerns require escalation to a licensed clinical professional.

Nice To Haves

Certified Medical Assistant or Licensed Practical Nurse credential preferred.
Additional cardiac or heart failure education or certification preferred.
Minimum of 2 years of clinical cardiology experience preferred.
Experience with heart failure patients strongly preferred.
Experience with transitional care management, chronic disease management, remote patient monitoring, or care coordination preferred.
Experience working in an outpatient cardiology or specialty practice preferred.

Responsibilities

Coordinate care for Heart Failure Program patients from hospital discharge through ongoing outpatient management.
Review hospital discharge summaries, emergency department records, cardiology notes, diagnostic results, medication changes, and treatment plans.
Identify patients needing timely post-discharge follow-up and ensure appointments are scheduled within clinical-team timeframes.
Coordinate follow-up visits with cardiologists, APPs, primary care providers, and other specialists.
Coordinate diagnostic testing, including echocardiograms, laboratory testing, imaging, and other heart failure-related studies.
Track patients with recent heart failure admissions, emergency department visits, worsening symptoms, or other indicators of increased clinical risk.
Maintain awareness of patient care plans and ensure appropriate follow-through on provider recommendations and orders.
Conduct scheduled telephone and electronic patient outreach according to program protocols.
Assess and document patient-reported symptoms and clinical-status changes, including weight, edema, shortness of breath, fatigue, dizziness, blood pressure, and heart rate.
Support remote patient monitoring by reviewing and communicating patient-generated health data as directed by the clinical team.
Identify possible worsening heart failure and promptly escalate concerns to the appropriate nurse, APP, or physician according to established protocols.
Assist with coordination of urgent evaluation when directed by the clinical team.
Reconcile medications after hospitalizations, emergency department visits, and other clinically significant encounters.
Verify that medication changes in discharge instructions and provider orders have been communicated to patients.
Reinforce prescribed medication regimens and help patients identify adherence barriers; escalate concerns related to access, affordability, pharmacy coordination, side effects, or understanding.
Support treatment-plan adherence without independently initiating, discontinuing, or modifying medications unless authorized and acting within established protocols.
Educate and reinforce education on heart failure self-management, daily weights, worsening symptoms, medication adherence, dietary and sodium recommendations, fluid management, blood pressure and heart-rate monitoring, contacting the practice, and when emergency evaluation may be necessary.
Reinforce individualized education from physicians, APPs, nurses, dietitians, pharmacists, and other Heart Failure Program members; help patients and families understand treatment plans and identify barriers to self-management.
Participate in post-hospital transition-of-care activities, including contacting patients within the program's defined timeframe, assessing recovery, reconciling medications, reviewing discharge instructions, and identifying barriers to care.
Ensure appropriate follow-up appointments and testing are scheduled after hospitalization, and communicate relevant clinical information to the care team.
Track patients after heart failure-related hospitalizations and identify opportunities to reduce avoidable readmissions.
Serve as a primary coordination resource for enrolled patients and collaborate with cardiologists, APPs, nurses, Medical Assistants, clinical care coordinators, and other practice staff.
Coordinate with hospitals, primary care providers, skilled nursing facilities, home health agencies, rehabilitation programs, pharmacies, and other external healthcare organizations.
Participate in interdisciplinary meetings, case reviews, team huddles, and Heart Failure Program initiatives.
Document patient contacts, assessments, education, interventions, communications, and follow-up accurately in the EMR; maintain accurate enrollment and tracking information.
Track completion of appointments, diagnostic testing, laboratory monitoring, and other care-plan elements, and maintain documentation supporting coordination, quality initiatives, and applicable billing or reporting requirements.
Protect patient confidentiality and comply with HIPAA and applicable organizational, state, and federal requirements.
Support program initiatives and quality-improvement activities related to outcomes, engagement, access, continuity of care, hospitalizations, readmissions, medication adherence, and care-plan compliance.
Identify recurring barriers, workflow issues, and improvement opportunities; communicate recommendations to program leadership.
Assist with developing and implementing standardized workflows, protocols, patient education materials, and tracking processes, and support collection and monitoring of program metrics as assigned.