RN Coordinator - Heart Failure Case Manager

$10k Sign-On Bonus available

• Collaborates with patients/caregivers to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum. 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.

• Bachelor's Degree BSN and/or MSN, Certification in Case Management - Preferred
• Bachelor's Degree BSN or equivalent Bachelor of Science - Required

• 1 year Case Management - Preferred
• 3 years RN clinical experience with heart failure or Pulmonary Artery Hypertension - Required

• Registered Nurse (RN) State And/Or Compact State Licensure RN (AZ or State Compact Licensure in good standing) - Required