Nurse Practitioner, Heart Failure Program Coordinator

NorthBay Health•Fairfield, CA

23h

About The Position

At NorthBay Health, the Heart Failure Program Coordinator – Nurse Practitioner (NP) is an Acute Care Nurse Practitioner (ACNP) serving as a core member of the multidisciplinary Heart & Vascular team. This role integrates advanced clinical practice with comprehensive oversight of the Heart Failure Program. The NP independently evaluates, diagnoses, and manages complex heart failure and cardiovascular patients in collaboration with supervising cardiologists and inpatient/outpatient teams. The NP provides patient care across both inpatient (Fairfield and Vacaville Hospitals) and outpatient settings while also leading program operations, quality initiatives, and performance improvement. The NP ensures evidence-based practice, supports seamless transitions of care, monitors Heart Failure quality metrics, manages the Remote Patient Monitoring (RPM) operations, and leads program improvement and community outreach efforts. The NP provides routine direct care to cardiovascular patients. Direct care duties include but are not limited to recheck and same day appointments. Performs physical examinations; performs or orders diagnostic tests; performs procedures and treatments; establishes diagnosis; prescribes medications; instructs patients and family members about medical conditions and treatment. Provides continuity for patient care with assigned physician practices. The Nurse Practitioner works in a collaborative/team model of care delivery to help maintain access to cardiovascular and improve overall patient health and satisfaction. The role includes approximately: 50% Inpatient Hospital Rounding (HF and CV patients), 30% Outpatient Clinical Care and 20% Heart Failure Program & Remote Patient Monitoring (RPM) Management. At NorthBay Health, we are guided by our values: Nurturing Care; Own It; Respect; Build Trust; and Hardwire Excellence. These principles lead us to our TRUE NORTH and inspire us to provide exceptional care. These values serve as the foundation of everything we do, guiding us to deliver individualized care with integrity and accountability. We are committed to fostering a culture of collaboration, where every team member is valued and empowered to contribute their best to the health and well-being of those we serve. This is an exciting time to join NorthBay Health. As an independent, nonprofit health system north of the San Francisco Bay Area, in the Napa/Solano Region, we are expanding our footprint across Solano, Yolo, and Napa counties to meet the evolving needs of our communities. With two acute-care hospitals—including a Level II Trauma Center and a modern maternity unit with a Level III Neonatal Intensive Care Unit (NICU)—along with a comprehensive cancer center, multiple urgent care facilities, and a growing network of primary and specialty clinics, we are investing in the future of care across the region. NorthBay Health we are home to advanced clinical programs and nationally recognized cardiovascular, neuroscience, and orthopedic services, as well as comprehensive surgical and outpatient specialties. Our commitment to excellence is reflected in our Magnet with Distinction designation for nursing (one of only 12 organizations nationwide) and recognition from U.S. News & World Report as “High Performing” in multiple clinical areas, including maternity care, heart failure, and stroke. NorthBay Medical Center has earned the High Performing designation in maternity care for four consecutive years. As the only locally governed health system in the region, we remain deeply rooted in our communities while growing into a trusted regional healthcare leader. If you are seeking meaningful work, collaborative teams, and the opportunity to help shape the future of healthcare in Northern California, you will find it at NorthBay Health. Join us with our commitment to excellence, to achieve our vision to be the trusted healthcare partner of choice for the communities we serve. To learn more about NorthBay Health's benefits, diversity statement and community please visit https://www.northbay.org/careers/

Responsibilities

Performs daily hospital rounds on heart failure and cardiovascular inpatients in collaboration with the cardiovascular treatment team to identify and prevent 30-day readmissions and decrease length of stay specifically among the congestive heart failure patient population.
Conducts admission H&Ps, orders diagnostic tests, interprets results, and develops treatment plans.
Manages acute decompensated heart failure, including IV diuretics, GDMT optimization, fluid/electrolyte management, hemodynamic monitoring, and device therapy coordination.
Participates in multidisciplinary rounds with cardiology, hospitalists, nursing, pharmacy, case management, and other care team members.
Coordinates comprehensive discharge planning to ensure effective transitions of care and reduce readmissions.
Provides inpatient heart failure education to patients and families.
Documents daily progress notes, clinical assessments, and treatment plans in the EMR.
Provides on-call coverage for Vacaville and Fairfield Hospitals, ensuring continuity of care and timely response to heart failure and cardiovascular inpatient needs.
Integrates RPM data (including high BP alerts and physiologic trends) into outpatient clinical decision-making to support early intervention and prevent avoidable ED visits or admissions.
Performs physical examinations and updates patient history.
Formulates a diagnostic impression and treatment plan as appropriate for patient needs.
Orders ancillary services as appropriate to meet patient needs.
Reviews all patient lab results and follows-up on abnormal test results. Reviews lab results with patient.
Requests specialty consultation when appropriate.
Provides patient education as appropriate.
Provides management of patients with chronic and/or acute cardiovascular conditions and develops treatment plans. Educating patients and their families on how to improve heart health. Ordering diagnostic tests and interpreting their results. Caring for patients experiencing cardiac emergencies.
Directs the overall clinical management of the patient and works closely with members of the cardiovascular team to ensure that patient is receiving appropriate services.
Updates patient summary record augmenting problems, clinical and social history, and medications as appropriate.
Identifies high risk problems and transfers care to appropriate physician.
Collaborates and communicates with appropriate physicians on patient care issues.
Evaluates and manages ambulatory HF and cardiovascular patients in clinic settings.
Adjusts and titrates GDMT, orders labs/imaging, and follows disease-specific care pathways.
Coordinates care with outpatient cardiologists, primary care, and specialty services.
Conducts transitional care visits and post-discharge follow-ups.
Collaborates with other members of the health care team to identify patient problems and develop plan of care to address needs of patient.
Provides assistance with inbox management for physician team members: review labs and imaging, address normal and abnormal results in conjunction with cardiovascular physician and/or nursing tem as appropriate, medication refills, and open/address inbox messages as appropriate.
Acts as a resource for staff, including supporting Team RNs and LVNs.
Assists in the development and implementation of special projects and programs and assists in the monitoring of results.
Documents all care rendered in the medical record in a timely fashion.
Works collaboratively with team members to ensure appropriate and efficient flow of patients through clinic appointments.
Complies with Clinical Practice Guidelines and other clinical standards established by the cardiovascular service line.
Communicates with physicians regarding follow-up, e.g., on results or referrals, and coordinates continuity of care.
Readily seeks input form supervising physician as needed.
Completes and submits coded fee tickets for each patient encounter.
Recommends and supports implementation of innovative strategies to enhance HF care, population health outreach, and RPM performance. Promotes teamwork and interdisciplinary collaboration across inpatient, outpatient, and community settings. Serves as liaison between cardiology, hospital medicine, nursing, pharmacy, case management, population health, and community agencies.
Oversees day-to-day operations and long-term development of the Heart Failure Program.
Leads HF quality initiatives, including readmission reduction and adherence to CMS/IAC/ACC accreditation standards.
Develops and maintains HF guidelines, pathways, and standards of care.
Monitors and reports HF quality metrics (readmissions, LOS, mortality, GDMT compliance, follow-up performance).
Analyzes registry and internal HF data to drive performance improvement.
Leads multidisciplinary HF committees, case reviews, and programmatic initiatives.
Provides education and training related to HF for staff, physicians, and community partners.
Collaborates with inpatient, outpatient, and population health teams to enhance continuity of care across the HF continuum.
Participates in strategic planning for Heart & Vascular Services and the HF Program.
Represents the HF Program in internal and external HF-related committees and quality workgroups.
Manages the Remote Patient Monitoring Program for heart failure and hypertension patients.
Reviews RPM alerts, including high blood pressure notifications, weight changes, and symptom alerts.
Performs timely triage, patient outreach, documentation, and clinical escalation as needed.
Coordinates with Population Health, primary care, cardiology, and nursing teams to ensure early intervention and prevent avoidable ED visits or readmissions.
Monitors RPM program performance and identifies opportunities to improve engagement, outcomes, and workflow efficiency.
Ensures efficient resource utilization to support high-quality HF care.
Maintains a safe and compliant working environment.
Supports innovation in patient care and clinical operations.
Uses EHR systems effectively for documentation, metrics tracking, and program oversight.