Location: Onsite MelroseWakefield Hospital

Job Overview

The Heart Failure Nurse Navigator serves as a clinical expert, patient advocate, and care coordinator for patients with congestive heart failure (CHF) across the continuum of care. This role is responsible for supporting heart failure patients from hospitalization through post-discharge recovery by facilitating evidence-based care, patient education, multidisciplinary collaboration, and seamless transitions between care settings.

The Heart Failure Nurse Navigator works closely with cardiologists, hospitalists, advanced practice providers, nursing staff, case management, social work, pharmacy, rehabilitation services, primary care providers, and community resources to optimize patient outcomes and reduce avoidable readmissions.

This position focuses on identifying high-risk heart failure patients, addressing barriers to care, promoting adherence to guideline-directed medical therapy, ensuring timely follow-up appointments, and empowering patients and caregivers through education on disease management, symptom recognition, medication compliance, nutrition, and self-management strategies.

The Navigator leads and coordinates heart failure initiatives throughout the organization, supports regulatory and quality metrics, facilitates

multidisciplinary heart failure rounds and care planning, and serves as a key resource to improve clinical outcomes, patient experience, and utilization management. Through proactive intervention and support, the Heart Failure Nurse Navigator plays an integral role in preventing readmissions, improving transitions of care, and enhancing the overall health and quality of life of patients living with heart failure.

Job Description

Minimum Qualifications:
1. Massachusetts RN Licensure.

2. 3 Years of acute care RN Experience.

3. Current Basic Life Support (BLS) Certification.

Preferred Qualifications:

1. Bachelor of Science in Nursing (BSN).

2. Experience with Cardiology/ Cardiac Service Lines and/or Heart Failure Programs.

• Experience managing patients with congestive heart failure and other cardiovascular conditions across inpatient and outpatient settings.
• Certification in Heart Failure Nursing (CHFN), Cardiac-Vascular Nursing (CV-BC), Case Management (CCM), or related specialty certification preferred.
• Experience working with multidisciplinary teams to coordinate complex patient care and improve quality outcomes.

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.

1. Assesses and facilitates coordination of multidisciplinary care across the care continuum.

2. Provides communication, advocacy, and education in a culturally competent manner.

3. Triages new patient referrals to ensure timely access to care.

4. Conducts post discharge follow up phone calls and serves as a liaison and patient advocate in navigating the healthcare system.

5. Provides patient education and supports utilizing knowledge of adult learning competencies and education resources to support complete, connected, and comprehensive care.

6. Collects and reports data from patient on barriers, hospital experience, health care, medications, prior treatments, etc.

7. Collaborates with multidisciplinary care team and expedites sequence of patient's care.

8. Serves as a liaison between patient and providers/clinicians to address patient’s needs.

9. Assesses patient's needs and ensures such needs are integrated into patient’s care plan.

10. Encourages and empowers patients to actively participate in decision making about their treatment and care.

Physical Requirements:

1. Occasional lifting of 30-35 lbs and turning patients.

2. Prolonged standing and walking.

3. Occasional twisting, bending, reaching, pushing/pulling, sitting, kneeling, and squatting.

4. Exposure to infectious disease and possible carcinogenic chemicals.

5. Exposure of blood-borne pathogens.

6. Requires fine manual dexterity to lift and maneuver patients.

7. Requires visual and aural acuity necessary to monitor patient care.

Skills & Abilities:

1. Ability to plan, implement, and evaluate individual patient care programs.

2. Ability to effectively communicate with patients, families, physicians, and healthcare team.

3. Ability to analyze, evaluate multiple solutions, and solve complex problems using well developed critical & analytical thinking skills.

4. Knowledge of and application of the nursing process.

5. Excellent time management skills needed to prioritize competing priorities.

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Nurse Navigator duties: Focuses on the patient's needs and helps guide the patient through the healthcare system and works to overcome obstacles that are in the way of the patient receiving the care and treatment they require.   A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.   The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.  Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range:

based on full-time equivalent