RN Nurse Navigator - Advanced Heart Failure

About this role

Department/Unit: HBD - Medicine Cardiology

Work Shift: Day (United States of America)

Salary Range: $84,783.00 - $131,414.00

RN Nurse Navigator Department of Cardiology Albany, NY

The Nurse Navigator is a registered nurse who serves as the primary point of contact for patients across the ambulatory care continuum. This role coordinates patient care across specialties and guides patients through complex treatment pathways, from diagnosis through treatment and follow-up.

The Nurse Navigator focuses on care coordination, patient advocacy, and program support, ensuring timely access to care, reducing barriers, and enhancing patient outcomes and experience. This role supports multidisciplinary care delivery and specialty program requirements, including accreditation standards.

The Heart Failure RN will primarily focus on managing patients with complex cardiovascular disease, including: Advanced heart failure patients Left Ventricular Assist Device (LVAD) patients Heart transplant recipients Patients requiring frequent clinical monitoring and coordination

Essential Duties and Responsibilities:

Care Coordination & Navigation • Serve as the primary point of contact for assigned patients across the care continuum

• Coordinate care across specialties including consults, diagnostics, procedures, and follow-ups

• Facilitate the appropriate and efficient delivery of healthcare services within and across systems by assessing patient needs and matching unmet needs with appropriate referrals and support services

• Track patient progression through care pathways and ensure completion of recommended care plans

• Proactively identify delays or gaps in care and intervene to maintain timely progression

Care Coordination & Multidisciplinary Collaboration • Participate in the coordination of care with the multidisciplinary team, promoting timely follow-up of treatment and supportive care recommendations

• Collaborate with physicians, APPs, nursing, social work, and ancillary services to ensure coordinated care delivery

• Collaborate with healthcare team members to build partnerships with community agencies and local organizations that support patient care, education, and psychosocial needs

• Participate in case discussions and program-based care planning

Transitions of Care • Support patients transitioning between care settings (hospital, outpatient, specialty services)

• Conduct post-discharge outreach and coordinate follow-up care

• Reinforce discharge instructions and ensure continuity of care

• Access & Patient Advocacy

• Act as a patient advocate by facilitating timely scheduling of appointments, diagnostic testing, and procedures to support the plan of care and promote continuity

• Expedite care when clinically appropriate to reduce delays in diagnosis and treatment

• Ensure patients understand next steps and assist in navigating the healthcare system

• Patient Education

• Assess, provide, and reinforce educational needs of patients, families, and caregivers, taking into consideration barriers to learning such as health literacy, language, and cultural factors

• Provide disease-specific education related to diagnosis, treatment options, procedures, and supportive care

• Reinforce provider education and ensure patient understanding of the care plan

Program/ Service Line Support • Support multidisciplinary care pathways across specialty programs (e.g., bariatrics, breast surgery)

• Participate in program development and workflow optimization

• Assist in maintaining compliance with program standards and accreditation requirements

• Collaborate with program teams to ensure efficient and coordinated care delivery

Patient Tracking & Registry Management • Maintain patient registries and tracking systems for program populations

• Monitor patient progression through care pathways and identify gaps

• Ensure follow-up on missed appointments or incomplete care steps

Documentation & EHR Utilization • Document all patient interactions and coordination activities in the EHR

• Ensure timely and accurate communication across the care team

Quality Improvement & Accreditation Support • Support quality improvement initiatives related to access, care coordination, and patient outcomes

• Assist with data tracking and reporting for program performance

• Support accreditation requirements for specialty programs (e.g., MBSAQIP, NAPBC)

• Ensure adherence to standardized care pathways and regulatory expectations

Leadership & Mentorship • Provide informal guidance and support to clinical and administrative staff related to care coordination workflows

• Serve as a resource for navigation processes and patient flow

• Participate in team-based problem solving and process improvement

• This role does not typically include formal leadership responsibilities

Clinical Knowledge & Standards • Demonstrate knowledge of evidence-based clinical guidelines and standards (e.g., NCCN, Commission on Cancer [CoC], and specialty-specific program requirements)

• Apply guideline-based knowledge to support patient navigation, education, and care coordination

• Maintain awareness of available specialty and community resources to support patients throughout the disease process

• Understanding of disease-specific care pathways relevant to assigned specialty programs

• Familiarity with accreditation standards and program requirements (e.g., bariatrics, breast surgery, oncology)

• Knowledge of care coordination best practices and ambulatory workflows

Qualifications: • Associate's Degree in Nursing - required

• Bachelor's Degree in Nursing (BSN) - preferred

• 3-5 years clinical nursing experience - required

• Experience in ambulatory care, specialty care, or care coordination preferred

• Strong clinical assessment and triage skills

• Excellent communication and patient education abilities

• Proficiency with electronic health records (Epic preferred)

• Experience supporting specialty programs (e.g., ba

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