Nurse Practitioner, Heart Failure Program Coordinator

Overview

Job Description At North Bay 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 inpatient 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.

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.

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.
• Requests specialty consultation when appropriate.
• 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 team 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…