RN Coordinator - Heart Failure Case Manager SHEA

Job Details

Primary City/State:
Shea Medical Center, 9003 E Shea Blvd Scottsdale, AZ 85260

Department:
Cardiovascular Navigation Services;

Shift: Day, Monday–Friday 8:00a.m.–4:30p.m.;

Location:

N.90th St &

E.Shea Blvd

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.
• Functions as a coordinator between the healthcare team, community and patients with HF.
• Establishes relationships with patients and caregivers.
• Supports and coordinates with patients, families and inpatient multidisciplinary team members to provide appropriate post‑acute pathways, screenings, assessments, care coordination, discharge planning, advance directives, early and post‑acute interventions, readmission risk mitigation, barriers to care, home support, medication management, and expectation setting; develops the post‑acute discharge and after‑care plan of the assigned evidence‑based care management pathway to promote a smooth transition from hospital discharge to a less acute or outpatient setting.
• Provides support and guidance to patients and caregivers regarding medication reconciliation, post‑discharge needs assessment, self‑management support, follow‑up care, supportive care, end‑of‑life decisions, community resources, and long‑term planning.
• Ensures the primary care provider is informed of the patient’s admission.
• Reviews discharge instructions with patients, including education required due to new medications or changes to medication regimens and disease‑specific “red flags” of complications.
• Conducts post‑hospitalization home visits, telephonic monitoring, or both, depending on the risk for readmission.
• Communicates clinical information and plans of care between the hospitalist, emergency room physician, specialists, primary care provider, community referrals, and other key healthcare providers involved in the case.
• Facilitates a smooth and timely transition from acute care to the post‑acute setting and primary care provider.
• Coordinates follow‑up care with primary care providers, specialists, and community providers regarding outpatient follow‑up appointments and plans of care.
• Ensures safe transmission of personal health information.
• Ensures post‑acute telephone calls and 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 collaborative communication among all healthcare team members—including patients, families, and significant others—to ensure integrated care services are targeted, appropriate, and beneficial from admission through discharge.
• Demonstrates technical skill and uses new technology to maintain clear, professional clinical documentation in the software database for cases in transition and for case assignment.
• Supports and participates in the development and maintenance of a Case Management Scorecard.

• 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).
• 1 year case management experience (preferred).
• 3 years RN clinical experience with heart failure or pulmonary arterial hypertension (required).

• Bachelor’s Degree BSN and/or MSN, Certification in Case Management (preferred).
• Bachelor’s Degree BSN or equivalent Bachelor of Science (required).

Registered Nurse (RN) State and/or Compact State Licensure (AZ or State Compact Licensure in good standing) – Required.