Coordinator - Heart Failure

About the role

Assumes active role in overall HF program development at JNJ. Works collaboratively as a team member with HF Specialists / APPs / RNs and ancillary AHPs to oversee population management of Heart failure ( HF) patients via real time identification of inpatients with diagnosis of HF on daily basis, tracks appropriateness of care setting and resource utilization, assists with identification of advanced HF patients, collaborates with clinical staff to ensure optimal GDMT, ensures appropriate discharge plan and coordinates both patient / family and staff education regarding HF. Works with hospital based Quality Improvement staff to maintain metrics on HF outcomes such as readmissions, Length of Stay and HF Quality indicators. Coordinates Quality Improvement processes for HF care including GWTG requirements. Oversees / provides Transitional care after discharge for patients transitioned to rehabilitation facilities, skilled facilities, personal care facilities, outpatient programs, and home with home care or home as per the Hospital to Home (H2H) guidelines. Provides coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings. Patient population ranges from young adulthood through late adulthood. Works closely with Outpatient HF Clinic staff. Job Duties Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. Follows established guidelines of the H2H Program and the Interact Tools, the transitions coach will implement. Provides consultation, education and support to patients and patient caregivers related to care giving responsibilities Maintains effective working relationship with medical team and all agency personnel providing care to the patient. Supports the medical staff during patient encounters as needed, performs diagnostic testing, patient education, and patient treatments as directed. Maintains effective collaborative communication with multidisciplinary team members in maintaining quality care for the patient. Documents all care management activities for each patient/client. Attends educational activities and departmental meetings as required. Prepares and submits timely and accurate statistical reports on HF related metrics and transitional care interventions. Performs other duties as assigned Minimum Qualifications Bachelor's Degree in Nursing 2 years cardiac nursing experience. Knowledge of hospital and community resources Experience with heart failure specific disease management knowledge Excellent verbal communication skills Computer skills Time management and prioritization skills Reliable transportation and auto insurance Self-directed and independent in structuring work processes CDL-C - Class C Driver's License_PA - State of Pennsylvania RN - Licensed Registered Nurse_NJ - State of New Jersey or RN - Licensed Registered Nurse_PA - State of Pennsylvania Preferred Qualifications Master's Degree in Nursing Heart Failure experience preferred. Additional Qualifications Physical Demands Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR. Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigne

Additional Information

Job Details Assumes active role in overall HF program development at JNJ. Works collaboratively as a team member with HF Specialists / APPs / RNs and ancillary AHPs to oversee population management of Heart failure ( HF) patients via real time identification of inpatients with diagnosis of HF on daily basis, tracks appropriateness of care setting and resource utilization, assists with identification of advanced HF patients, collaborates with clinical staff to ensure optimal GDMT, ensures appropriate discharge plan and coordinates both patient / family and staff education regarding HF. Works with hospital based Quality Improvement staff to maintain metrics on HF outcomes such as readmissions, Length of Stay and HF Quality indicators. Coordinates Quality Improvement processes for HF care including GWTG requirements. Oversees / provides Transitional care after discharge for patients transitioned to rehabilitation facilities, skilled facilities, personal care facilities, outpatient programs, and home with home care or home as per the Hospital to Home (H2H) guidelines. Provides coaching to clients to enable them to gain disease self-management skills and cope with transitions across care settings. Patient population ranges from young adulthood through late adulthood. Works closely with Outpatient HF Clinic staff. Job Description

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