Description
At NorthBay Health, the Heart Failure Program Coordinator – Nurse Practitioner (NP) is an Acute Care Nurse Practitioner (ACNP) serving as a core member of the multidisciplinary Heart & Vascular team. This role integrates advanced clinical practice with comprehensive oversight of the Heart Failure Program. The NP independently evaluates, diagnoses, and manages complex heart failure and cardiovascular patients in collaboration with supervising cardiologists and inpatient/outpatient teams. The NP provides patient care across both inpatient (Fairfield and Vacaville Hospitals) and outpatient settings while also leading program operations, quality initiatives, and performance improvement. The NP ensures evidence-based practice, supports seamless transitions of care, monitors Heart Failure quality metrics, manages the Remote Patient Monitoring (RPM) operations, and leads program improvement and community outreach efforts. The NP provides routine direct care to cardiovascular patients. Direct care duties include but are not limited to recheck and same day appointments. Performs physical examinations; performs or orders diagnostic tests; performs procedures and treatments; establishes diagnosis; prescribes medications; instructs patients and family members about medical conditions and treatment. Provides continuity for patient care with assigned physician practices. The Nurse Practitioner works in a collaborative/team model of care delivery to help maintain access to cardiovascular and improve overall patient health and satisfaction. The role includes approximately: 50% Inpatient Hospital Rounding (HF and CV patients), 30% Outpatient Clinical Care and 20% Heart Failure Program & Remote Patient Monitoring (RPM) Management.
PRIMARY JOB DUTIES
INPATIENT RESPONSIBILITIES (50%)
Performs daily hospital rounds on heart failure and cardiovascular inpatients in collaboration with the cardiovascular treatment team to identify and prevent 30-day readmissions and decrease length of stay specifically among the congestive heart failure patient population.
Conducts admission H&Ps, orders diagnostic tests, interprets results, and develops treatment plans.
Manages acute decompensated heart failure, including IV diuretics, GDMT optimization, fluid/electrolyte management, hemodynamic monitoring, and device therapy coordination.
Participates in multidisciplinary rounds with cardiology, hospitalists, nursing, pharmacy, case management, and other care team members.
Coordinates comprehensive discharge planning to ensure effective transitions of care and reduce readmissions.
Provides inpatient heart failure education to patients and families.
Documents daily progress notes, clinical assessments, and treatment plans in the EMR.
Provides on-call coverage for Vacaville and Fairfield Hospitals, ensuring continuity of care and timely response to heart failure and cardiovascular inpatient needs.
OUTPATIENT RESPONSIBILITIES (30%)
Integrates RPM data (including high BP alerts and physiologic trends) into outpatient clinical decision-making to support early intervention and prevent avoidable ED visits or admissions.
Performs physical examinations and updates patient history.
Formulates a diagnostic impression and treatment plan as appropriate for patient needs.
Orders ancillary services as appropriate to meet patient needs.
Reviews all patient lab results and follows-up on abnormal test results. Reviews lab results with patient.
5. Requests specialty consultation when appropriate.
6. Provides patient education as appropriate.
Provides management of patients with chronic and/or acute cardiovascular conditions and develops treatment plans. Educating patients and their families on how to improve heart health. Ordering diagnostic tests and interpreting their results. Caring for patients experiencing cardiac emergencies.
Directs the overall clinical management of the patient and works closely with members of the cardiovascular team to ensure that patient is receiving appropriate services.
Updates patient summary record augmenting problems, clinical and social history, and medications as appropriate.
Identifies high risk problems and transfers care to appropriate physician.
Collaborates and communicates with appropriate physicians on patient care issues.
Evaluates and manages ambulatory HF and cardiovascular patients in clinic settings.
Adjusts and titrates GDMT, orders labs/imaging, and follows disease-specific care pathways.
Coordinates care with outpatient cardiologists, primary care, and specialty services.
Conducts transitional care visits and post-discharge follow-ups.
Collaborates with other members of the health care team to identify patient problems and develop plan of care to address needs of patient.
Provides assistance with inbox management for physician team members: review labs and imaging, address normal and abnormal results in conjunction with cardiovascular physician and/or nursing tem as appropriate, medication refills, and open/address inbox messages as appropriate.
Acts as a resource for staff, including supporting Team RNs and LVNs.
Assists in the development and implementation of special projects and programs and assists in the monitoring of results.
Documents all care rendered in the medical record in a timely fashion.
Works collaboratively with team members to ensure appropriate and efficient flow of patients through clinic appointments.
Complies with Clinical Practice Guidelines and other clinical standards established by the cardiovascular service line.
Communicates with physicians regarding follow-up, e.g., on results or referrals, and coordinates continuity of care.
Readily seeks input form supervising physician as needed.
Completes and submits coded fee tickets for each patient encounter.
HEART FAILURE PROGRAM COORDINATION & RPM OVERSIGHT (20%)
Recommends and supports implementation of innovative strategies to enhance HF care, population health outreach, and RPM performance. Promotes teamwork and interdisciplinary collaboration across inpatient, outpatient, and community settings. Serves as liaison between cardiology, hospital medicine, nursing, pharmacy, case management, population health, and community agencies.
Heart Failure Program Coordination
Oversees day-to-day operations and long-term development of the Heart Failure Program.
Leads HF quality initiatives, including readmission reduction and adherence to CMS/IAC/ACC accreditation standards.
Develops and maintains HF guidelines, pathways, and standards of care.
Monitors and reports HF quality metrics (readmissions, LOS, mortality, GDMT compliance, follow-up performance).
Analyzes registry and internal HF data to drive performance improvement.
Leads multidisciplinary HF committees, case reviews, and programmatic initiatives.
Provides education and training related to HF for staff, physicians, and community partners.
Collaborates with inpatient, outpatient, and population health teams to enhance continuity of care across the HF continuum.
Participates in strategic planning for Heart & Vascular Services and the HF Program.
Represents the HF Program in internal and external HF-related committees and quality workgroups.
Remote Patient Monitoring (RPM) Program Coordination
Manages the Remote Patient Monitoring Program for heart failure and hypertension patients.
Reviews RPM alerts, including high blood pressure notifications, weight changes, and symptom alerts.
Performs timely triage, patient outreach, documentation, and clinical escalation as needed.
Coordinates with Population Health, primary care, cardiology, and nursing teams to ensure early intervention and prevent avoidable ED visits or readmissions.
Monitors RPM program performance and identifies opportunities to improve engagement, outcomes, and workflow efficiency.
Ensures efficient resource utilization to support high-quality HF care.
Maintains a safe and compliant working environment.
Supports innovation in patient care and clinical operations.
Uses EHR systems effectively for documentation, metrics tracking, and program oversight.
Qualifications
Education:
Master's required. Graduate of an accredited nursing program including a Nurse Practitioner Program.
Licensure/Certifications:
Current CA licensure as a Nurse Practitioner and Board Certification by the American Nurse Credentialing Center, American Academy of Nurse Practitioners,
American Association of Critical Care Nurses, or Pediatric Nursing Certification Board.
Current AHA or equivalent certification in CPR.
Maintains a current DEA license for schedule 2 drugs and above.
Maintains a current Furnishing Number for medications.
Experience:
Minimum of two years as a Nurse Practitioner practicing in cardiology preferred.
New Graduate Adult Gerontology and Acute Care Nurse Practitioners welcome to apply.
Must have at least 5 years nursing experience in a hospital or specialty care environment, treating patients with cardiovascular illnesses.
Skills:
Demonstrates ability to evaluate patient's physical and emotional status. Assess patient conditions, educate patients and family members about medical options, prescribe medications and treatments, and perform other duties to support patients.
Demonstrates ability to provide patient care based on age-related needs.
Demonstrates current knowledge and skill in providing appropriate care for patients in the following age groups: Adult, Young Adult, and Geriatric.
Demonstrates clear credentials check through the AHP process.
Demonstrates ability to clearly set behavioral limits.
Demonstrates ability to mentor others. Demonstrates excellent written and verbal communication skills.
Acts as advocate when representing colleagues and uses appropriate methods to clearly convey information to others in an engaging way.
Interpersonal Skills:
Demonstrates the True North values.
The True North values are a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Health.
The True North values principles consist of Nurture/Care, Own It, Respect Relationships, Build Trust and Hardwire Excellence.
Works with others respectfully and openly to achieve shared goals.
Compensation:
$98.52 to 119.75 per hour based on years of experience doing the duties of the role.
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