Heart Failure Nurse Navigator

Position Summary

Position: Heart Failure Nurse NavigatorLocation: St. Petersburg, FloridaDepartment: Cardiology – Orlando Health Florida Medical Clinic/Bayfront Medical GroupSchedule: Full-time | Monday–Friday | 40 hours/week

 

Start Your Career with Confidence at Orlando HealthOrlando Health is one of Florida’s most respected healthcare systems, known for our unwavering commitment to excellence, patient care, and employee satisfaction. As part of the Orlando Health Florida Medical Clinic/Bayfront Medical Group, you’ll join an organization that values your work, supports your growth, and provides competitive benefits starting your very first day.

 

We believe our team is our greatest strength. That’s why we invest in you from the start, with comprehensive benefits, career development opportunities, and a culture rooted in compassion, innovation, and teamwork.

 

Job SummaryLeverages best practices and evidence-based guidelines to deliver high quality, efficient, consistent, and coordinated care to patients diagnosed with heart failure, in collaboration with multidisciplinary clinical teams and partnered organizations and services.

Responsibilities

Essential Functions

• Compile and analyze data used to identify hospitalized acute and chronic heart failure patients, and distribute such patient lists to other departments to encourage data consistency and promote multidisciplinary collaboration.
• Provide detailed and contemporary education and discharge materials tailored specifically to patient needs via booklets, videos, classes, and other channels, as necessary, to educate heart failure patients, their families, and their caregivers.
• Demonstrate the highest levels of compassion, nursing skill, and technical competency in all patent interactions.
• Establish and maintain a positive working relationship with patients to foster patient engagement and drive treatment compliance.
• Document patient care in a knowledgeable, skillful, and consistent manner meeting all required and regulatory standards.
• Perform assessments of patient needs, available resources, precipitating factors, and educational opportunities to develop/revise individualized care plans, and to evaluate patient progress toward attaining expected outcomes.
• Determine and anticipate post-acute patient needs, including services such as home health support, durable medical equipment, and REACH Team/Social Services to maximize care outcomes across the care continuum.
• Serve as an advocate for the patient, collaborating with cross-functional and multidisciplinary teams, to enable high quality and reliable care transitions and access to medications.
• Act as the principal facilitator between Orlando Health and contracted vendors to improve the longitudinal care for heart failure patients, including coordinating with the paramedicine program team, leveraging remote patient monitoring solutions, and connecting patients with palliative care services, as necessary, among other such programs.
• Coordinate with the Heart Failure Clinic to ensure patients are scheduled for follow up appointments post-acutely, either for virtual or in-person care, to reduce the likelihood for re-hospitalization.
• Coordinate telephonic or virtual visit outreach to all heart failure patients within three days of discharge from the hospital to assess their clinical progress, evaluate their understanding of the condition, verify follow up appointments are calendared, and encourage healthy behaviors and medication adherence.
• Actively participate in program-specific collaborative opportunities, including multidisciplinary rounds.
• Serve on, or actively engage with, related quality and readmission task forces, and regularly attend corporate and site-specific heart failure collaborative sessions, including AHA “Get with the Guidelines” sessions, SNF/DON collaborative meetings, and Corporate Heart Failure CC team building sessions.
• Collaborate with appropriate outlying facilities and agencies to ensure protocols are aligned with evidence-based guidelines.
• Understand the principles of growth and development over the life span and/or disease state and implement interventions, as appropriate, while being sensitive to cultural needs and patient preferences.
• Communicate appropriate information regarding patient condition or unit concerns to other health care team members.
• Exhibit respect to patients and families by showing awareness of legal issues and patients’ rights, consistently providing a safe and clean care environment, and ensuring all other safety, health, and regulatory standards are satisfactorily met and satisfied.