The Care Manager RN Heart Failure Coordinator plans, organizes, and arranges services for Heart Failure (HF) patients by collaborating with the healthcare team and providing guidance on medication reconciliation, post-discharge needs, and self-management support. This role focuses on ensuring a smooth transition from hospital to outpatient care by coordinating across the health care continuum, including follow-up care and communication between various providers.
Requirements summary
Candidates must possess a Bachelor of Science (BSN) and an active Registered Nurse (RN) license in Arizona or a Compact State. A minimum of three years of relevant RN clinical experience is required, specifically with pulmonary hypertension or heart failure, including experience in areas like cardiac cath, telemetry, or cardiology.
30p Located at N. 90th St & E. Shea Blvd Must meet minimum requirements BSN Registered AZ RN license or Compact State RN Three years RN clinical experience with pulmonary hypertension or heart failure - cardiac cath, telemetry, cardiac, or cardiology
Overview
Looking to be part of something more meaningful?
At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients.
You’ll have opportunities to make a difference.
From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact.
HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives.
Visit honorhealth.com/benefits to learn more.
Join us.
Let’s go beyond expectations and transform healthcare together.
HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area.
The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more.
With nearly 17,000 team members, 3,700 affiliated providers and close to 2,000 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona.
Learn more at HonorHealth.com.
Responsibilities
Job Summary The Care Manager RN Heart Failure Coordinator plans, organizes and arranges services for heart Failure (HF) patients with members of the healthcare team.
This position provides information and guidance to patients and their caregivers regarding medication reconciliation, assessment of post-discharge needs, self-management support and follow-up care post discharge.
Essential Functions Collaborates with patients/caregivers to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum.
Benefits
Diverse Benefits Portfolio
Key areas of focus include: Functions as a coordinator between the healthcare team, community and patients with HF.
Establish relationship with patient/caregiver.
Supports and coordinates with patient, family and inpatient multi-disciplinary team members providing appropriate post-acute level pathway, screenings, assessments, care coordination, discharge planning, advance directives, early & post-acute interventions, readmission risk, barriers to care outpatient including home support, medication management, expectation, etc., post-acute discharge plan, after-care plan of the assigned evidenced based care management pathway to promote a smooth transition primarily from a hospital discharge to a less acute or outpatient setting.
Provides support and guidance to patients and their caregivers regarding medication reconciliation, assessment of post-discharge needs, self-management support, follow-up care post discharge, supportive care, end-of-life decisions, community resources, and long-term planning needs.
Assures PCP is aware of patient’s admission Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific “red flags” of complications Conduct effective post-hospitalization home visits, telephonic monitoring, or both depending on the risk for readmission.
Provides effective communication of clinical information and plan of care between the Hospitalist, Emergency Room Physician, Specialists, PCP and community referrals; as well as other key healthcare providers involved in the case.
Facilitates a smooth and timely transition from acute care to the post acute setting and PCP Coordinates follow-up care with PCP/ Specialists/Community providers regarding outpatient follow-up appointment and plan of care.
Communicates key information regarding inpatient stay and discharge plans to patient’s PCP and healthcare team.
Ensures safe transmission of personal health information.
Ensures post-acute telephone, home visits are conducted and after care issues are followed-up as determined by case needs to assess self-care monitoring and system management Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.
Demonstrates technical skill and new forms of technology in maintaining clear and professional clinical documentation in software data base for cases followed under transition and for case assignment.
Supports and participates in the development and maintenance of Case Management Scorecard.
Education Bachelor's Degree BSN and/or MSN, Certification in Case Management - Preferred Bachelor's Degree BSN or equivalent Bachelor of Science - Required Experience 1 year Case Management - Preferred 3 years RN clinical experience with heart failure or Pulmonary Artery Hypertension - Required Licenses and Certifications Registered Nurse (RN) State And/Or Compact State Licensure RN (AZ or State Compact Licensure in good standing) - Required
