Heart Failure Nurse Navigator MelroseWakefield Hospital

Tufts Medicine

1d•$91,879 - $117,150•Onsite

About The Position

The Heart Failure Nurse Navigator is a clinical expert, patient advocate, and care coordinator for patients with congestive heart failure across the continuum of care. The role supports patients from hospitalization through post-discharge recovery by facilitating evidence-based care, patient education, multidisciplinary collaboration, and transitions between care settings. The Navigator works with cardiologists, hospitalists, advanced practice providers, nursing staff, case management, social work, pharmacy, rehabilitation services, primary care providers, and community resources to optimize outcomes and reduce avoidable readmissions. The position identifies high-risk patients, addresses barriers to care, promotes adherence to guideline-directed medical therapy, ensures timely follow-up, and educates patients and caregivers about disease management, symptom recognition, medication compliance, nutrition, and self-management. The Navigator coordinates organizational heart failure initiatives, supports regulatory and quality metrics, facilitates multidisciplinary rounds and care planning, and helps improve clinical outcomes, patient experience, and utilization management. The role also provides professional and nonprofessional nursing care in accordance with physician orders and helps patients navigate the healthcare system and overcome obstacles to needed care.

Requirements

Massachusetts RN licensure.
Three years of acute care RN experience.
Current Basic Life Support (BLS) certification.
Ability to plan, implement, and evaluate individual patient care programs.
Ability to communicate effectively with patients, families, physicians, and the healthcare team.
Ability to analyze and evaluate multiple solutions and solve complex problems using critical and analytical thinking.
Knowledge and application of the nursing process.
Excellent time management skills to prioritize competing priorities.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Experience with cardiology or cardiac service lines and/or heart failure programs.
Experience managing patients with congestive heart failure and other cardiovascular conditions across inpatient and outpatient settings.
Certification in Heart Failure Nursing (CHFN), Cardiac-Vascular Nursing (CV-BC), Case Management (CCM), or a related specialty.
Experience working with multidisciplinary teams to coordinate complex patient care and improve quality outcomes.

Responsibilities

Assess and facilitate coordination of multidisciplinary care across the care continuum.
Provide communication, advocacy, and education in a culturally competent manner.
Triage new patient referrals to ensure timely access to care.
Conduct post-discharge follow-up phone calls and serve as a liaison and patient advocate in navigating the healthcare system.
Provide patient education and use adult learning competencies and education resources to support complete, connected, and comprehensive care.
Collect and report patient information about barriers, hospital experience, health care, medications, and prior treatments.
Collaborate with the multidisciplinary care team and expedite the sequence of patient care.
Serve as a liaison between patients and providers or clinicians to address patient needs.
Assess patient needs and ensure they are integrated into the care plan.
Encourage and empower patients to participate actively in decisions about their treatment and care.
Identify high-risk heart failure patients and address barriers to care.
Promote adherence to guideline-directed medical therapy and ensure timely follow-up appointments.
Coordinate heart failure initiatives, support regulatory and quality metrics, and facilitate multidisciplinary heart failure rounds and care planning.
Help prevent readmissions, improve transitions of care, and enhance patient outcomes and quality of life.