Heart Failure Ambulatory RN

SUMMARY

The Heart Failure Ambulatory RN serves as a clinical partner to MMG physicians and advanced practice providers, with a specialized focus on the management of patients with heart failure across the continuum of care. This role emphasizes patient safety, telephone triage, post-hospital transition of care, prevention of avoidable readmissions, and optimization of chronic disease management through evidence-based practice.

The Ambulatory RN comprehensively assesses patient health status to support the development, execution, and evaluation of individualized and disease specific care plans. This role utilizes clinical judgment, data, and evidence-based guidelines to drive high-quality care delivery. Key dimensions of this position include care transitions, patient safety, quality outcomes, teamwork, patient engagement, and population health management.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Heart Failure Population Management & Care Coordination

· Serves as a primary RN resource for patients with heart failure, supporting longitudinal disease management across outpatient and post-acute settings

· Collaborates with physicians and advanced practice providers to develop, implement, and evaluate evidence-based heart failure care plans

· Monitors patients’ clinical status, including symptom progression, weight trends, medication adherence, and self-management behaviors

· Identifies patients at high risk for decompensation or hospitalization and escalates care appropriately

· Coordinates care across the continuum, including primary care, cardiology, hospital teams, and community resources

Transitions of Care (Post-Discharge Support)

· Leads and supports transitional care management (TCM) for heart failure patients following hospital or emergency department discharge

· Conducts timely post-discharge outreach, including symptom assessment, medication reconciliation, and identification of barriers to recovery

· Ensures patients have appropriate follow-up appointments, diagnostics, and medication access post-discharge

· Reinforces discharge instructions, including daily weights, diet (e.g., sodium restriction), medication adherence, and symptom escalation guidelines

· Identifies early signs of clinical deterioration and intervenes to prevent avoidable readmissions and ED utilization

· Collaborates with inpatient teams, case management, and external facilities to ensure safe and effective care transitions

Patient Assessment, Education & Engagement

· Performs independent nursing assessments using strong clinical judgment and critical thinking skills

· Provides targeted education and coaching to heart failure patients and families, including:

o Disease understanding and trajectory

o Medication management (e.g., diuretics, GDMT adherence)

o Self-monitoring (daily weights, symptom recognition)

o Lifestyle modifications and preventative care

· Delivers education during end-of-visit consultations, nurse visits, and telephonic outreach

· Engages patients in self-management and shared decision-making, promoting adherence and improved outcomes

Clinical Operations & Symptom Management

· Manages and triages incoming patient communication, including symptom calls and clinical advice requests, with prioritization of high-risk heart failure concerns

· Utilizes standardized workflows and protocols to support safe, efficient patient disposition (e.g., home care, same-day visits, emergency department, or escalation to provider)

· Performs and interprets assessments related to cardiovascular care, including:

o Electrocardiograms

o CardioMEMS

o Cardiac monitoring (e.g., Holter monitors)

o Laboratory and diagnostic results

· Recognizes abnormal findings and communicates changes in patient condition to providers in a timely manner

· Conducts independent nurse visits as appropriate, including education, follow-up assessments, and care plan reinforcement

· Conducts Cardiology Acute Care visits as appropriate, including IV fluid and medication administration (e.g., diuretics), patient education, and care coordination (e.g., diagnostic imaging, labs.).

Medication Management & Safety

· Supports medication management in collaboration with providers, including refills, titration support, and adherence monitoring

· Participates in management of specialized programs (e.g., anticoagulation) as applicable

· Performs medication reconciliation, particularly during transitions of care, to reduce risk of adverse events

Care Coordination & Resource Referrals

· Addresses social determinants of health that may impact heart failure outcomes (e.g., access to medications, food, transportation)

· Connects patients to supportive services, including:

· Care management / complex care programs

· Social work and community resources

· Health coaching and disease management programs

· Community resources

Documentation, Communication & Compliance

· Documents all patient assessments, interventions, and outcomes accurately in the electronic medical record

· Communicates effectively with providers and interdisciplinary team members to ensure continuity and safety of care

· Maintains patient confidentiality in accordance with HIPAA regulations

· Supports quality initiatives aimed at improving heart failure outcomes, reducing readmissions, and enhancing patient experience

EDUCATION

Associate’s Degree – Nursing

BLS

MONTAGE VALUES

Employees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.

EXPERIENCE

A minimum of 3 years of practice as an RN (acute care experience preferred) with at least 1 year of Heart Failure experience. Experience with electronic medical record documentation. Working knowledge of quality standards and evidence-based practice.

REQUIREMENTS

California licensed Registered Nurse. Strong letters of recommendation (2).

SKILLS AND ABILITIES

· Strong interpersonal and communication skills

· Patient-centric problem-solving skills

· Critical thinking skills

· Epic clinical documentation

· Ability to effectively collaborate across a multidisciplinary care team