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Inpatient Heart Failure Care Coordinator
2 months ago
This role, in collaboration with Case Management, coordinates the seamless transition of care from one healthcare setting to another, encompassing inpatient, Home Health Care, Skilled Nursing Facility, and Rehab facilities.
Key Responsibilities- Educate patients and/or family members regarding their clinical condition, treatment, postoperative course, and role in recovery.
- Collaborate and communicate with a wide range of multidisciplinary providers to achieve exceptional patient experiences and optimal outcomes.
- Identify eligible inpatients using established program criteria and deliver education to patients and caregivers, including teach-back interventions.
- Support non-cardiology primary providers with HF guideline-directed medical therapies plans, including liaising with pharmacy.
- Coordinate post-discharge care to ensure a seamless transition, collaborating with pharmacist on medication reconciliation and scheduling post-discharge clinic appointments.
- Communicate with patient's PCP and post-acute care providers regarding post-discharge care expectations and develop a plan for scheduled check-ins with patients and caregivers.
- Collect and document key data points into appropriate systems, helping provide QA of data integrity and performing interval reviews of readmission cases to identify opportunities for improvement.
- Bachelor of Science degree in Nursing
- Registered nurse with current unrestricted Massachusetts state license
- Heart failure nurse certification highly desirable
- Minimum of 5 years of clinical nursing experience working with heart failure cardiology patient population
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected, and accessible care experiences to consumers across Massachusetts. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine.
