**Overview** The Cardiac Nurse Navigator, in collaboration with the cardiologists, APN's, and the entire healthcare team, oversees and supports the cardiac patient and their significant other(s). The Cardiac Nurse Navigator is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of selected patients with primary cardiac care needs. The navigator is accountable for a designated case load determined by the careful daily selection of eligible patients. They assess, plan, and facilitate, with patients/families and healthcare professionals involved in the patient's care to meet treatment goals, and arrange for the appropriate next steps. Oversees Interfacility Coordination and handoff between acute & outpatient services. **Responsibilities** 1. Participates in the collaboration with physicians, nursing staff, and interdisciplinary team in the assessment, planning, implementation and evaluation of care for selected patients and their families. - All patients who are admitted for medical care will be screened for potential eligibility to the Cardiac Transitions of Care (TOC) program. All eligible patients will be enrolled. - Meets directly with the patient/family to assess needs, based on assessment and prior evaluation from care coordinators/case management and develop an individualized needs assessment. - Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care. - Develops a TOC plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. In addition to aligning with patient quality metrics. Confirms the patient has a primary care provider, cardiology providers upon discharge and refers appropriately to a primary care provider and/or cardiologist if needed. - Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next appropriate level of care. - Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life and clinical outcomes. Consults with other community agencies and committees to identify potential resources to support patients and their families. Will actively work to find community partners. - Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow-up care, and referral to community services. - Provides patients and families with community resources and discharge care coordination options. - Provides appropriate patient and family education regarding diagnosis, treatment, and self-care management and documents outcomes in the medical record. - Ensures timely follow up appointments with appropriate care providers. - Participates actively on appropriate workgroups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the cardiac and transition of care team locally. - Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised. Medical records reflect that each patient's discharge plan is re-assessed in response to changes in patient's needs and Social Determinants of Health. - Completes all other necessary duties with attention to detail and in a timely manner. 2. Monitor readmission rates for Medicare and all payers, and implement needed performance improvement projects to improve scores in collaboration with the cardiac team. 3. Collaborates with the cardiac team to help ensure that ACC metrics and goals are met. 4. Other duties and/or projects as assigned. 5. Adheres to HMH Organizational competencies and standards of behavior. **Qualifications** Education, Knowledge, Skills and Abilities Required: 1. Graduate of an NLN/AACN accredited program in nursing. 2. Bachelor's Degree or equivalent years of cardiovascular experience. 3. Minimum 2 years of experience as a registered nurse. 4. Computer skills to include Google Docs and data entry. 5. Strong organization and problem solving skills. 6. Exceptional communication skills to enable communication and collaboration with physicians, patients, families, and ancillary staff. 7. Excellent critical thinking skills. 8. Ability to work in a fast paced team environment. 9. Ability to prioritize and multitask. 10. Ability to make sound, independent clinical judgements and act professionally under pressure. 11. Demonstrate ability to provide age appropriate skills, cultural competency and customer service skills and health literacy. Licenses and Certifications Required: 1. NJ State Professional Registered Nurse License. 2. AHA Basic Health Care Life Support HCP Certification. 3. Advanced Cardiac Life Support Certification. 4. Certification in area of specialty. **Job ID** _2024-158364_ **Department** _JFK Cardiovascular Clinic_ **Site** _JFK Medical Center_ **Job Location** _US-NJ-Edison_ **Position Type** _Full Time with Benefits_ **Standard Hours Per Week** _40_ **Shift** _Day_ **Shift Hours** _Days_ **Weekend Work** _Every Other Weekend_ **On Call Work** _No On-Call Required_ **Holiday Work** _Three of 6_