Inpatient Heart Failure Care Coordinator

2 days ago


Boston, Massachusetts, United States Tufts Medicine Full time
Job Overview

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. The successful candidate will educate patients and/or families regarding their clinical condition, treatment, postoperative course, and their role in recovery.

Key Responsibilities
  • Identify eligible inpatients using established program criteria
  • Deliver education to patients and caregivers, including teach-back interventions
  • Perform risk assessment using standardized tools
  • Support non-cardiology primary providers with HF guideline-directed medical therapies plans, including liaison with pharmacy
  • Collaborate with other members of the inpatient care team to develop discharge care plans
  • Coordinate post-discharge care to ensure a seamless transition
  • Collaborate with pharmacists on medication reconciliation
  • Schedule post-discharge clinic appointments
  • Communicate with patients' PCPs and post-acute care providers regarding post-discharge care expectations
  • Develop a plan for scheduled check-ins with patients and caregivers
Qualifications
  • 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 populations

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. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity, and/or expression, marital status, or any other characteristic protected by federal, state, or local law.



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