Coordinator - Heart Failure

Jefferson Health Plans•Corporate Center-South Jersey (KCV), NJ

1d•$82,243 - $117,197•Onsite

About The Position

Assumes an active role in the overall Heart Failure (HF) program development at JNJ. Works collaboratively as a team member with HF Specialists, Advanced Practice Providers (APPs), Registered Nurses (RNs), and ancillary Allied Health Professionals (AHPs) to oversee the population management of Heart Failure (HF) patients. This involves the real-time identification of inpatients with a diagnosis of HF on a daily basis, tracking the appropriateness of care settings and resource utilization, assisting with the identification of advanced HF patients, and collaborating with clinical staff to ensure optimal Guideline-Directed Medical Therapy (GDMT). The role ensures an appropriate discharge plan and coordinates patient/family and staff education regarding HF. Works with hospital-based Quality Improvement staff to maintain metrics on HF outcomes such as readmissions, Length of Stay, and HF Quality indicators. Coordinates Quality Improvement processes for HF care, including Get With The Guidelines (GWTG) requirements. Oversees and provides Transitional care after discharge for patients transitioned to rehabilitation facilities, skilled facilities, personal care facilities, outpatient programs, and home with home care or home, adhering to the Hospital to Home (H2H) guidelines. Provides coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings. The patient population ranges from young adulthood through late adulthood. Works closely with Outpatient HF Clinic staff.

Requirements

Bachelor’s Degree in Nursing
2 years cardiac nursing experience
Knowledge of hospital and community resources
Experience with heart failure specific disease management knowledge
Excellent verbal communication skills
Computer skills
Time management and prioritization skills
Reliable transportation and auto insurance
Self-directed and independent in structuring work processes
CDL-C - Class C Driver's License_PA - State of Pennsylvania
RN - Licensed Registered Nurse_NJ - State of New Jersey or RN - Licensed Registered Nurse_PA - State of Pennsylvania

Nice To Haves

Master’s Degree in Nursing
Heart Failure experience preferred

Responsibilities

Oversee population management of Heart Failure (HF) patients via real-time identification of inpatients with a diagnosis of HF on a daily basis.
Track appropriateness of care setting and resource utilization.
Assist with the identification of advanced HF patients.
Collaborate with clinical staff to ensure optimal Guideline-Directed Medical Therapy (GDMT).
Ensure appropriate discharge plans.
Coordinate patient/family and staff education regarding HF.
Work with hospital-based Quality Improvement staff to maintain metrics on HF outcomes (readmissions, Length of Stay, HF Quality indicators).
Coordinate Quality Improvement processes for HF care, including GWTG requirements.
Oversee and provide Transitional care after discharge for patients transitioned to various facilities or home.
Provide coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings.
Interact with co-workers, visitors, and other staff consistent with the values of Jefferson.
Implement H2H Program and Interact Tools as a transitions coach.
Provide consultation, education, and support to patients and patient caregivers related to caregiving responsibilities.
Maintain effective working relationships with the medical team and all agency personnel providing care to the patient.
Support medical staff during patient encounters as needed, perform diagnostic testing, patient education, and patient treatments as directed.
Maintain effective collaborative communication with multidisciplinary team members in maintaining quality care for the patient.
Document all care management activities for each patient/client.
Attend educational activities and departmental meetings as required.
Prepare and submit timely and accurate statistical reports on HF related metrics and transitional care interventions.
Perform other duties as assigned.

Benefits

Medical (including prescription)
Supplemental insurance
Dental
Vision
Life and AD&D insurance
Short- and long-term disability
Flexible spending accounts
Retirement plans
Tuition assistance
Voluntary benefits (access to group rates on insurance and discounts)
Tuition discounts at Thomas Jefferson University (after one year of full-time service or two years of part-time service)