SUMMARY
The Registered Nurse (RN) serves as a central clinical partner in the management of patients with heart failure, focusing on proactive care, early intervention, and seamless coordination across settings. This role emphasizes prevention of clinical deterioration, patient self-management, and reduction of avoidable hospital utilization through close collaboration with providers and interdisciplinary teams.
ESSENTIAL DUTIES AND RESPONSIBILITES Includes but not limited to the following
- Proactive Patient Management & Risk Stratification
- Maintain and update comprehensive Congestive Heart Failure Registry databases, ensuring accuracy, completeness, and compliance with regulatory standards.
- Oversees a panel of heart failure patients, prioritizing those at highest risk for decompensation or readmission
- Continuously evaluates patient status through review of symptoms, weight patterns, medication use, and overall disease stability
- Identifies subtle changes in condition and initiates early interventions in collaboration with providers
- Utilizes clinical protocols and judgment to determine appropriate next steps, including escalation of care when needed
- Post-Acute Follow-Up & Readmission Prevention
- Act as primary liaison between Congestive Heart Failure Clinic and hospital Transitional Care Management team to ensure seamless communication, coordination of care, and timely support of CHF patient discharges.
- Provides structured follow-up for patients recently discharged from the hospital or emergency department
- Conducts outreach to assess recovery progress, confirm understanding of care plans, and address barriers
- Reviews and reconciles medications to ensure safe and appropriate use post-discharge
- Confirms completion of follow-up appointments, diagnostics, and access to prescribed therapies
- Intervenes early when warning signs emerge to prevent unnecessary emergency visits or rehospitalizations
- Remote Monitoring & CardioMEMS Management
- Supports ongoing management of patients enrolled in remote monitoring programs, including CardioMEMS, with a focus on early identification of clinical changes
- Reviews transmitted pulmonary artery pressure data and trends, recognizing patterns that may indicate fluid overload or instability
- Applies clinical judgment and established protocols to determine when intervention or provider escalation is needed
- Collaborates with providers to facilitate timely adjustments to treatment plans based on hemodynamic data
- Conducts patient outreach as needed to assess symptoms, reinforce care plans, and support adherence to monitoring requirements
- Ensures patients understand proper device use, transmission expectations, and when to report symptoms outside of routine monitoring
- Coordinates with device vendors, specialty teams, and internal staff to support enrollment, onboarding, and ongoing program participation
- Integrates remote monitoring data into the broader clinical picture, aligning findings with symptoms, labs, and other diagnostic information
- Patient Coaching & Self-Management Support
- Delivers practical, patient-centered education to improve understanding of heart failure and day-to-day management
- Coaches patients and caregivers on:
- Recognizing early symptoms and when to seek care
- Daily monitoring practices (e.g., weight tracking, daily upload of CardioMEMS readings)
- Medication routines and adherence strategies
- Nutrition and lifestyle considerations
- Reinforces education across multiple touchpoints, including visits, phone outreach, and virtual care
- Encourages patient participation in care decisions to strengthen engagement and accountability
- Clinical Triage & Episodic Care Support
- Serves as a first point of clinical contact for incoming patient concerns, prioritizing urgency and risk
- Applies established pathways to guide patient disposition, including same-day evaluation, home management, or escalation
- Supports in-clinic care delivery through nurse-led visits focused on reassessment, education, and stabilization
- Assists with acute symptom management in collaboration with providers, including administration of ordered therapies and coordination of diagnostics
- Medication Oversight & Safety
- Partners with providers to support safe and effective medication use, including titration support and adherence monitoring
- Facilitates timely prescription refills and addresses barriers to medication access
- Performs thorough medication reviews, particularly during care transitions, to reduce risk of discrepancies or adverse events
- Integrated Care Coordination
- Works across disciplines to align care plans and ensure continuity between outpatient, inpatient, and community settings
- Collaborates with primary care, cardiology, hospital teams, and ancillary services to support comprehensive care delivery
- Connects patients with additional resources such as care management programs, social services, and community-based support
- Addresses non-clinical factors that may impact outcomes, including transportation, food access, and financial barriers
- Documentation, Communication & Program Support
- Maintains accurate, timely documentation of all patient interactions and clinical activities within the medical record
- Communicates clearly with providers and team members regarding changes in patient status and care needs
- Adheres to all regulatory and privacy standards, including HIPAA compliance
- Supports program goals related to quality, patient experience, and utilization management
- EDUCATION and/or EXPERIENCE
- Graduate of an accredited Registered Nursing program (Associate Degree in Nursing [ADN] or Bachelor of Science in Nursing [BSN] required)
- Current, active Registered Nurse (RN) license in the State of California, in good standing
Qualifications
- Bachelor of Science in Nursing (BSN) strongly preferred
- Minimum of 2–3 years of clinical nursing experience in cardiology and heart failure
- Experience with chronic disease management, care coordination, or population health programs
- Familiarity with remote monitoring technologies (e.g., CardioMEMS) and/or ambulatory care workflow
Condition of employment
Proof of identity and legal authority to work in the U.S. is a condition of employment. Cypress Healthcare Partners/Salinas Valley Health Clinics will not sponsor applicants for work visas.
The range displayed on this job posting reflects the target for new hire salaries for this position.
