The Registered Nurse will manage a panel of heart failure patients by providing proactive care, remote monitoring, and clinical triage to prevent hospital readmissions. They will also serve as a liaison between clinical teams to ensure seamless care coordination and patient education.
Requirements summary
Candidates must hold an active California Registered Nurse license and have completed an accredited nursing program. A minimum of 2–3 years of clinical experience in cardiology or heart failure is required, with a BSN preferred.
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
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
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.
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