Heart Failure Coordinator

Overview

The Heart Failure Coordinator is a registered nurse responsible for coordinating evidence-based care for patients with heart failure across the continuum of care. This role partners with physicians, advanced practice providers, case management, pharmacy, rehabilitation, and community resources to improve clinical outcomes, support self-management, reduce avoidable readmissions, and promote timely follow-up after hospitalization. The coordinator provides patient and caregiver education, monitors symptoms and trends, supports guideline-directed therapy and transitions of care, and helps ensure compliance with heart failure quality standards and program goals.

Responsibilities

• Coordinate care for patients with heart failure across inpatient, outpatient, and post-discharge settings to support safe transitions and continuity of care.
• Provide individualized education to patients and caregivers on heart failure diagnosis, symptom recognition, daily weights, medication adherence, sodium and fluid management, activity, and when to seek medical attention, consistent with AHA/AAHFN heart failure education principles.
• Complete and reinforce discharge planning, including medication reconciliation, follow-up appointment coordination, barrier assessment, and early post-discharge outreach to reduce readmissions.
• Monitor clinical status through patient calls, symptom review, weight and vital sign trends, laboratory results, and remote monitoring or implantable device data; communicate significant findings and escalation needs to the licensed provider.
• Support implementation and coordination of guideline-directed medical therapy, diagnostic testing, procedures, prior authorizations, and specialty referrals under provider direction.
• Collaborate with physicians, advanced practice providers, primary care, pharmacy, social work, rehabilitation, home health, and community resources to address clinical, psychosocial, financial, and access barriers to care.
• Document assessments, interventions, outcomes, and care plans accurately in the medical record and applicable program databases.
• Track quality and program metrics such as readmissions, follow-up compliance, patient education completion, and heart failure performance measures; participate in quality improvement and certification readiness activities.
• Serve as a clinical resource for staff and patients regarding heart failure best practices, self-management support, and evidence-based care pathways.
• Perform clinic-based nursing support as needed, including rooming patients, obtaining ECGs, coordinating labs, and assisting with device interrogation and monitoring workflows within scope of practice.
• Any other duties as assigned within scope of practice.

Qualifications

Education

• Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred.

Experience

• Minimum of 3 years of RN clinical experience required; cardiology, heart failure, ICU, case management, care coordination, or chronic disease management experience preferred.
• Experience with patient education, discharge planning, remote monitoring, and interdisciplinary care coordination preferred.

Licenses and Certifications

• Current Registered Nurse (RN) license in the applicable state or compact state required.
• Basic Life Support (BLS) required; Advanced Cardiac Life Support (ACLS) preferred or required based on practice setting.
• Heart failure, cardiac, or case management certification preferred when applicable.