RN Cardiac Services Navigator

TMC Health Care

TMC Health Care is Southern Arizona's regional nonprofit hospital system with Tucson Medical Center at its core. Each day staff come to work to use their skills and expertise to improve the health of the entire community, from birth to the end of life.

Provides proactive, patient-facing navigation for cardiac patients across the inpatient-to-outpatient continuum, with emphasis on AMI, CHF, chest pain, STEMI, structural heart, and other high-risk cardiovascular populations. Rounds on identified patients while still hospitalized, provides education, coordinates discharge readiness, and ensures appropriate cardiology follow-up appointments, medication access, remote monitoring, cardiac rehabilitation, home health, or other wraparound services are arranged prior to discharge whenever feasible.

Maintains quality, registry, accreditation, and data-reporting responsibilities while using outcomes data to improve transitions of care, reduce avoidable readmissions, and support growth and integration of Cardiovascular Services.

• Assists in the development, implementation, and revision of cardiac navigation workflows, discharge coordination processes specific to the cardiac patient population, follows nursing protocols, standards of care, patient education programs, and utilizes applicable tools.
• Oversees tracking and reporting related to cardiac patient throughput, follow-up appointment completion, readmissions, quality outcomes, registry requirements, and program performance; provides data to appropriate cardiac, quality, and service line committees to initiate changes and improve outcomes.
• Assists in the development of strategic plans for the growth of Cardiovascular Services.
• Identifies high-risk cardiac patients requiring advanced nursing judgment, including AMI, CHF, chest pain, STEMI, structural heart, and other cardiovascular patients; utilizes holistic assessment, relevant clinical data, and risk factors to determine the appropriate navigation plan for the patient and family.
• Participates in Pre-, Peri-, Post-Procedure, and inpatient rounding activities directly involving interactions with the patient and/or family; may include treatment plan review, education, testing coordination, medication access review, appointment scheduling, discharge planning support, medical record review, status reports, follow-up phone calls, and other activities determined to be relevant.
• Engages assigned cardiac patients while they are still hospitalized to confirm understanding of diagnosis, procedure, medications, warning signs, follow-up expectations, and available support resources.
• Coordinates with TMCOne Cardiology, PCP offices, hospitalists, APPs, case management, discharge planners, nursing staff, and cardiology practices to ensure cardiology follow-up appointments are scheduled before discharge whenever feasible.
• Supports transitional care workflows by helping arrange or coordinate referrals for remote patient monitoring, Dispatch Health, Bridge Care, cardiac rehabilitation, home health, follow-up labs, medication reconciliation, and other services needed to reduce avoidable readmissions.
• Responsible for outreach efforts to establish and maintain positive working relationships with key customers and partners, including physicians, office staff, diagnostic staff, nurses, case management, social services, TMCOne, Bridge Care, cardiac rehabilitation, and other transitional care stakeholders.
• Provides, manages and coordinates care; applies analytical reasoning, rational problem-solving skills, using evidence-based information and clinical judgment; acts as clinical resource to other staff members
• Works closely with Directors, Support Services, Materials Management, Supervisors and other personnel to establish and maintain inventory levels, medicines, specialty supplies and equipment.
• Consults and communicates with physicians, APPs, hospitalists, nursing staff, clinic teams, and care coordination partners to ensure proper care, discharge planning, and timely follow-up of patients.
• Assists with unit needs assessment of equipment, environment, new technology, for the development of capital budgeting in conjunction with unit manager.
• Provides critical patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure safe patient care.
• Ensures accurate data collection, coordinates documentation efforts of staff and physicians, and educates the teams on the importance of documentation needed for quality reporting, accreditation, transitional care billing support, follow-up completion, and readmission improvement efforts.
• Keeps current on technology, regulatory, and operational trends in the health care industry as it relates to critical patient care.
• Provides direction, instruction and guidance for all staff involved in the critical care of patients.
• Notifies appropriate physicians regarding any unusual or unexpected events or problems requiring…