The Heart Failure RN Patient Navigator provides a range of client centered services for those with chronic, complex disease process and/or high utilization patterns. This role will provide assessment, care planning, education, coordination and consultation support to patients, families/caregivers and clinical staff as the client transitions across the continuum of care. The RN Navigator is a liaison with physicians, office practices, nurses, interdisciplinary team, quality management, clinical documentation and associated registries in the hospital network and community to coordinate medically appropriate cost-effective care. The Navigator applies clinical expertise for the medical management across the continuum of care to optimize functional status and quality of life for HF patients. The primary goal is to promote and support an environment of excellent patient care, meet regulatory guidelines and performance metrics, track individual and population based outcomes and promote our program in the community and surrounding areas.
- Recognized Leader: Only Magnet Hospital in Syracuse, highlighting our professional nursing staff.
- Shared Governance: Unit practice counsel and open door guiding principle gives all our nurses a voice.
- Advancement: Strong orientation, leadership development programs and generous tuition allowance.
- Work/Life: Self-scheduling options to balance your work/life and school calendars.
What you will do:
- Manages the case load of patients with chronic disease under the direct supervision of a physician.
- Improves health care access, promotes client knowledge and behavior change.
- Communicates with inpatient hospital staff to facilitate post-hospitalization follow-up and facilitates the transition of care to and from hospitalization, ER visit, Long term care facility, or assisted living facilities.
- Communicates matrix reporting from MGPS to Heart Failure Program, Cardiovascular Service Line Management and Providers.
- Serves as a resource and consultant for best practice information as it relates to the heart failure program and services available within our network.
- Effectively educates the care team, including patient and their support, in medical management and quality of life matters related to heart failure.
- Participates in the development and evaluation of the heart failure care path and educational material.
- Provides focused attention on Service Line specific initiatives to include patient satisfaction, adherence to medical plan, re-admission rates, and length of stay.
- Coordinates and maintains readiness for compliance with regulatory agencies.
- Supports effective case management to maximize healthcare outcomes, facilitate wellness and identify/correct service delivery complications.
- Collecting, storing and reporting data collection for the development and quality improvement of the heart failure program.
- Establishes and maintains Heart Failure Patient & Family Advisory Council.
- Develop plan and advance the program to meet, exceed and/or improve metrics.
- Manages associated specialty clinics.
- Participates in and applies knowledge of research, current concepts and guidelines to practice.
- Complies with insurance requirements for disease management, assists with coordinating care of the uninsured/unassigned patient referrals.
- Collaborates with service line to provide formal feedback for registries and governing bodies through performance development process.
- Collaborates with service line to achieve unit and organizational quality improvement and outcome based initiatives.
- Provide information as program ambassador to represent the service and promote the program.
Education, Training, Experience, Certification and Licensure:
- Bachelor’s Degree in Nursing required with three years’ progressive experience in the related field preferred. Certification/licensure as required by regulatory agency. Certification is recommended in related field.
- Graduate of an accredited School of Nursing and current licensure as a Registered Nurse in New York State.
- Demonstrated high clinical competence with commitment to interdisciplinary teamwork, relationship-based care, EBP and ability to carry out responsibilities with minimal supervision.
- Maintains annual mandatory competencies and requirements for service line.
- Commitment to, and knowledge of, primary care and community health.
- Chronic disease education and management experience.
- Working knowledge of computers, keyboarding, and various programs for reporting and presenting information (Excel, Word, PowerPoint, Outlook, etc.)
- Clinical ladder advancement with national certification opportunities.
- Career advancement to senior leadership roles such as Manager, Director or Administrative roles.
- We, St Joseph’s Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
- To be world-renowned for passionate patient care and outstanding clinical outcomes.
- In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good, Reverence in honoring the dignity of every person, Excellence in expecting the best of ourselves and others; Integrity in being faithful to who we say we are.
Work Environment and Hazards:
- Clinical setting. Exposure Class I
- Medium work: must be able to lift 25 pounds frequently; occasionally lifting maximum of 50 pounds. Will require ability to stand, walk, sit, bend, twist, squat and reach.
Work Contact Group:
- All services, medical staff, patients, visitors, and various regulatory and professional agencies.
- Service Line Manager/Director.