Nurse Patient Navigator, Heart Failure Disease Management, 40 Hours, Days
Location: Worcester, MA
Salary: ZAR 200000 - 300000
Time type: Full time
Posted on: 6 Days Ago
Exemption Status: Exempt
Schedule Details: Monday through Friday, 8 AM - 4 PM
Signing Bonus: May be available; eligibility will be confirmed during the interview process.
Everyone Is a Caregiver
At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence, and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve.
I. Major Responsibilities:
- Facilitates the entry of patients into the diagnostic and/or treatment system and coordinates their care including family involvement. Follows patients throughout the continuum of health care services across multiple departments.
- Assists patients in understanding their diagnosis, treatment options, recommended follow-up, and resources available.
- Utilizes nursing process to comprehensively assess patients’ physical and psychological status.
- Evaluates progress of patients along the continuum and is responsible for professional and personal modifications along with the healthcare team as appropriate.
- Coordinates and participates in multidisciplinary planning conferences, collaboratively assists with the development of patient summaries for use by the care team.
- Work with inpatient heart failure team to identify patients and coordinate hospital care.
- Patient education prior to discharge.
- Assist with the development of a plan of care following discharge from the hospital.
- Coordination of patient care across the continuum of care including inpatient, outpatient, LTC, hospice, palliative care, and home care.
- Communicate regularly with physicians and advance practice providers regarding ongoing patient needs.
- Attend weekly team meetings.
- Work with cardiac bundle navigator for longitudinal care.
- Proper assessment and triage skills to ensure patients are getting the level of care needed.
- Follow up on interventions.
- Disease management:
- Post-discharge telephone calls with documentation.
- Database management.
- Remote monitoring surveillance (HeartLogic and CardioMEMS).
- Screen patients for additional support services such as Digital Health/MIH.
- HF Clinic Support:
- Assist physician/APP in managing in-basket messaging.
- Authorize prescription refills as directed by supervising physician.
- Coordinate with Admin to schedule tests and procedures post MD/APP clinic.
- Provide patients with test results, assess, and evaluate patients understanding and refer to physician if necessary.
- Write orders, return to work notes (per physician verbal orders).
- Screen test results for abnormalities and need for immediate intervention.
- Follow up on patients after complex clinic visit to ensure they understand and are following discharge orders. Monitor effectiveness of interventions.
- Accurately document providers’ verbal orders and implement plan.
- Prepare, explain, and assist with instructions regarding procedures and treatments.
- Support specialty clinics and follow up on testing, medication authorization.
Other:
- Assist with ongoing work with CV quality department to ensure department is meeting regulatory and quality guidelines and goals.
- Maintain/develop patient database accurately, and able to interpret and analyze data to spot trends in care.
- Work in a fast-changing environment to meet the needs of this complex patient population.
- Provide education to staff and affiliated providers about the program.
- Demonstrate ability to work with confidential and controlled information.
- Other duties as assigned.
Qualifications:
- 2-5 years of Heart Failure RN experience.
- Experience with Epic.
- Excellent written and verbal communication skills necessary.
- Ability to work in a strong team environment.
- Flexibility and strong work ethic.
- Excellent assessment and documentation skills.
- Enthusiastic about working with disease management.
- Proficient and accurate in documentation.
- Licensed RN, BSN preferred.
II. Position Qualifications:
License/Certification/Education:
Required:
- Bachelor’s degree in Nursing.
- Current Massachusetts Registered Nurse licensure and registration.
Preferred:
- Master's Degree in Nursing.
Experience/Skills:
Required:
- Minimum of 5 years nursing experience.
- Excellent teaching, consultation, and customer service skills.
- Excellent critical thinking skills.
- Demonstrates leadership experience.
- Excellent verbal and written communications skills.
- Computer literate with knowledge of Microsoft Office products.
Preferred:
- Skilled with utilization of EMR and other software.
- Experience with Project Management.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community, and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.
As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.
If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at We will make every effort to respond to your request for disability assistance as soon as possible.
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