Job DescriptionThe Heart Failure Navigator is a specialized clinical professional responsible for coordinating and optimizing care for patients with heart failure across the continuum-from inpatient care through discharge and outpatient management. The role focuses on improving clinical outcomes, reducing readmissions, achieving LOS targets, and ensuring adherence to evidence-based heart failure guidelines.
The Heart Failure Navigator facilitates seamless transitions across the continuum of care, reduces readmissions, improves compliance with guideline-directed therapy, and enhances the patient experience through education and coordinated follow-up.
Patient Care Coordination
- Identify and follows heart failure patients during inpatient admission and outpatient encounters
- Coordinate multidisciplinary care (cardiology, primary care, nursing, case management, pharmacy, rehab)
- Facilitate smooth transitions of care from hospital to home, rehab, or outpatient follow-up
- Ensures post hospital discharge appointments are in place prior to discharge
Clinical Management & Monitoring
- Ensure adherence to evidence-based clinical guidelines (e.g., GDMT for heart failure)
- Monitor patients for clinical deterioration and intervene early
- Collaborate with providers to optimize medical therapy
- Review labs, imaging, and diagnostics relevant to heart failure management
Patient & Family Education
- Provide education on:
- Disease process and symptom recognition
- Medication adherence
- Dietary restrictions (e.g., low sodium)
- Daily weight monitoring and self-management
- Reinforce discharge instructions and self-care plans
Readmission Reduction & Outcomes Management
- Develop and implement strategies to reduce 30-day readmissions
- Conduct post-discharge follow-up calls or visits
- Track and report quality metrics (LOS, readmissions, mortality, compliance)
- Monitors LOS and develops strategies to help achieve targets
Care Transition & Discharge Planning
- Ensure timely follow-up appointments (cardiology and primary care)
- Coordinate discharge needs (home care, equipment, medications)
- Address barriers to care such as transportation or medication access
Quality Improvement & Program Development
- Participate in heart failure program development and accreditation initiatives
- Analyze data to identify trends and opportunities for improvement
- Support regulatory compliance (e.g., Joint Commission, CMS metrics)
Documentation & Reporting
- Maintain accurate documentation in the electronic medical record
- Track patient outcomes and registry data
- Prepare reports for leadership and quality committees
QualificationsRequired:
1. Bachelor's in Nursing or related field.
2. Valid State or national Nursing License.
3. 2 years of experience in Acute Care or relevant area.
Preferred:
1. Heart Failure certification (e.g., CHFN) preferred
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits - Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance.
- Short-Term and Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan: Employer match, additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
