Registered Nurse – Congestive Heart Failure Program

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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