- Identifies eligible inpatients using established program criteria
- Delivers education to the patient and caregivers, including teach back interventions
- Performs risk assessment using standardized tool
- Supports non-cardiology primary providers with HF guideline directed medical therapies plan, including liaising with pharmacy
- Collaborates with other members of inpatient care team to develop discharge care plan
- Coordinates post-discharge care to ensure seamless transition
- Collaborates with pharmacist on medication reconciliation
- Schedules post-discharge clinic appointments
- Communicates with patient's PCP and post-acute care providers regarding post-discharge care expectations
- Develops a plan for scheduled check-ins with patients and caregivers
- Calls patient by phone at pre-determined intervals
- Ensure patient adherence with care plan (e.g., medications, self-monitoring)
- Communicates closely with the patient and their family during the first 30 days post-discharge to ensure they are fully informed and supported during the transition period
- Reminds patients of upcoming appointments
- Helps resolve obstacles to adherence and wellbeing
- Collects and documents key data points into appropriate systems (e.g., risk assessment score)
- Helps provide QA of appropriate systems to ensure data integrity
- Performs interval reviews of readmission cases to identify opportunities for improvement
- Recommends improvements or development of standards of practice for inpatient, post-acute, home and ambulatory care of patients
- Participates in the development and evaluation of program tools and interventions, such as patient education materials, risk assessment tools, and databases
- Provides educational in- and outreach to providers in the network
- Works in collaboration with heart failure disease management NP and RN
- Bachelor of Science degree in Nursing
- Registered nurse with current unrestricted Massachusetts state license
- Heart failure nurse certification highly desirable
- Minimum of 5 years of clinical nursing experience working with heart failure cardiology patient population
-
RN Nurse Navigator
2 weeks ago
Tufts Medical Center Boston, United States Full timeWe're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you. · Job Profile Summary · This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses ...
-
RN Nurse Navigator
1 week ago
Tufts Medical Center Boston, United StatesWe're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you. · Job Profile Summary · This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses ...
-
RN Nurse Navigator
4 days ago
Tufts Medical Center Boston, United StatesWe're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you. · Job Profile Summary · This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role foc ...
-
RN Nurse Navigator
1 week ago
Tufts Medical Center Boston, United StatesJob Description · We're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you. · Job Profile Summary · This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, ...
-
Mass General Brigham Boston, United States RegularAlzheimer Therapeutics Program Nurse Navigator Description GENERAL SUMMARY/ OVERVIEW STATEMENT: · This is a full-time position in the Neurology Department collaborating with multiple providers in a multidisciplinary team. The incumbent will spend 50% effort (average 20 hours/wee ...
-
Registered Nurse Navigator Hospitalist
4 days ago
NCH Healthcare System Needham, United States Full timeDEPARTMENT: Hospital Based Physicians · LOCATION: 350 7th Street North, Naples, FL, 34102 · WORK TYPE: Full Time · WORK SCHEDULE: 12 Hour Day · ABOUT NCH · NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised ...
-
Oncology Nurse Navigator
4 weeks ago
South Shore Health Weymouth, United StatesIf you are an existing employee of South Shore Health then please apply through the internal career site. · Requisition Number: · R-16131 · Facility: · LOC Columbian Street101 Columbian StreetWeymouth, MA 02190 · Department Name: · SSH Medical Oncology Cancer Center · Stat ...
-
Oncology Nurse Navigator
1 week ago
Newton-Wellesley Hospital(NWH) Newton, United States**Oncology Nurse Navigator** · The Oncology Nurse Navigator is responsible for the day-to-day operations of the Cancer Center is responsible for maintaining and improving daily operations for oncology as a service line with interdisciplinary cancer team, to include coordinating a ...
-
Registered Nurse Oncology Navigator
1 week ago
AtlantiCare Regional Medical Center Weymouth, United States Full timeAtlantiCare Regional Medical Center · 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. · Egg Harbor Twp, NJ · POSITION SHI ...
-
Registered Nurse, Neurology Clinic, Ambulatory
3 weeks ago
Boston Children's Hospital Boston, United States Full timeJob Summary · This Staff Nurse will be responsible for:Triaging and managing patient messaging and communication via phone and patient portal · Assessing, planning, implementing, evaluating and modifying plans of care for a specific patient assignment throughout the healthcare c ...
-
Speech and Language Pathologist
1 week ago
Easter Seals of Massachusetts Inc Boston, MA, United StatesSpeech-Language Pathologist (SLP) · CF's welcome to apply · Do your professional goals and passions align with providing individualized services that focus on the power of unlocking every client's full potential? Are you a new graduate who wants to experience multiple settings in ...
-
Physical Therapist
1 week ago
Easter Seals of Massachusetts Inc Boston, MA, United StatesPhysical Therapist (PT) · Do your professional goals and passions align with providing individualized services that focus on the power of unlocking every client's full potential? Are you a new graduate who wants to experience multiple settings in order to find your ideal patient ...
-
Breast Imaging Quality Navigator
1 week ago
Mass General Brigham Boston, United States RegularBreast Imaging Quality Navigator Description Full-Time 40 hours. Mon – Fri 7:30am to 4:00pm. · Reporting directly to the Clinical Manager of Breast Imaging with a dotted line to the Breast Imaging Leadership team, including the Division Chief. The Breast Imaging Quality Naviga ...
-
Travel Nurse RN
4 weeks ago
Host Healthcare Boston, United States Full timeHost Healthcare is an award-winning travel healthcare company with an immediate opening for this Registered Nurse - Telemetry in Boston, MA. · Why Choose Host Healthcare? · Passionate and transparent team members have made Host Healthcare the agency of choice for new and experien ...
-
Registered Nurse
3 weeks ago
Dorset County Hospital NHS Foundation Trust Boston, United States PermanentJob summary · Dorset County Hospital is recruiting a registered nurse to work with Dorset's Targeted Lung Health Check Programme. · The service is a Lung cancer screening programme which invites participants aged between years old who either smoke currently or have smoked previo ...
-
Travel Nurse RN
1 week ago
Host Healthcare Boston, MA, United StatesHost Healthcare is an award-winning travel healthcare company with an immediate opening for this · Registered Nurse - · ICU · in · Boston , · MA . · Why Choose Host Healthcare? · Passionate and transparent team members have made Host Healthcare the agency of choice for new a ...
-
Travel Nurse RN
1 week ago
Host Healthcare Boston, United States Full timeHost Healthcare is an award-winning travel healthcare company with an immediate opening for this Registered Nurse - Emergency Room in Boston, MA. · Why Choose Host Healthcare? · Passionate and transparent team members have made Host Healthcare the agency of choice for new and exp ...
-
Travel Nurse RN
1 week ago
Host Healthcare Boston, United StatesHost Healthcare is an award-winning travel healthcare company with an immediate opening for this · Registered Nurse - · Cardiac Cath Lab · in · Boston , · MA . · Why Choose Host Healthcare? · Passionate and transparent team members have made Host Healthcare the agency of choice f ...
-
GI Oncologist opening in Boston, MA
6 days ago
Britt Medical Search Boston, United StatesSeeking BE/BC Medical Oncologist, specializing in the care of Gastrointestinal Cancer Patients. · Primarily focused on the care of GI cancer patients with potential opportunity for additional disease based specialization. · The position offers excellent administrative and nurse ...
-
Mass General Brigham Boston, United States RegularDean, School of Nursing at MGH Institute of Health Professions Description Leadership Profile · Dean, School of Nursing · The MGH Institute of Health Professions (IHP), an independent, interprofessional graduate school founded by Massachusetts General Hospital and the only de ...
Inpatient Heart Failure Nurse Navigator - Boston, United States - Tufts Medical Center
![Default job background](https://contents.bebee.com/public/img/bg-user-ex-1.jpg)
Description
We're saving lives, building careers, and reimagining healthcare. We can't wait to grow alongside you.Job Overview
This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes: inpatient, Home Health Care, Skilled Nursing Facility, Rehab facilities. Educates the patient and /or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes.
Job Description
Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.
Inpatient Care
Transitions of Care
Post-Discharge Care
Data Collection
Program Development
Qualifications
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at