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Inpatient Heart Failure Nurse Navigator

4 weeks ago

Boston, Massachusetts, United States Tufts Medical Center Full time

Job Overview

This position coordinates the transition of care from one healthcare setting to another, including inpatient, home health care, skilled nursing facilities, and rehabilitation centers. The nurse navigator educates patients and their families about their clinical condition, treatment, and postoperative course, ensuring a seamless transition and optimal patient outcomes.

Key Responsibilities

  • Identify eligible inpatients using established program criteria
  • Deliver education to patients and caregivers, including teach-back interventions
  • Support non-cardiology primary providers with heart failure guideline-directed medical therapies

Transitions of Care

  • Collaborate with the inpatient care team to develop a discharge care plan
  • Coordinate post-discharge care to ensure a smooth transition
  • Communicate with patient's primary care physician and post-acute care providers

Post-Discharge Care

  • Call patients by phone at pre-determined intervals to ensure adherence to the care plan
  • Communicate closely with patients and their families during the first 30 days post-discharge

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 patients