Job Description

Location: St. Dominic Hospital
Department: MHVI - 7275
Employment Type: Full Time 80
Shift: Day
Other Shift Details:
Job Code: 8647

Coordinates and delivers patient care within the chronic care model for heart failure and other indicated chronic illnesses. Coordinates and does patient teaching along with helping to manage post-acute care compliance. Works in tandem with the in-patient heart failure program to provide optimal outcomes and management across the continuum of the chronic disease state. Maintains standards of the department and the hospital

Associates degree (BSN preferred) from an accredited school of nursing. Minimum of three years' clinical expertise required. Current Mississippi RN license required; certification in specialty area desirable . Employee must demonstrate ability to recognize patients' individual needs based on medical conditions, age, limitations and planned procedures. Requires oral and written communication skills; professional affiliations. This position has been determined to have a high risk of occupational exposure to blood-borne pathogens


  • Helps coordinate the daily operation of the chronic care clinic: scheduling, patient visits, post care processes, and follow up.
  • Performs appropriate education and teaching according to best practice guidelines for appropriate disease management.
  • Performs RN functions within the chronic care clinic: vital signs, lab draws, venipuncture, IV med administration, medical reconciliation, etc
  • Performs patient care documentation within the designated EMR for the clinic model.
  • Performs in the patient advocate and liaison role for chronic disease patients. Helping to facilitate their disease management efforts both around clinic visits and in other modalities such as remote monitoring to assist with compliance and adherence to best practices for outcomes.
  • Coordinates post discharge care with outpatient HF chronic care clinic or other available agencies to ensure proper transitional care.
  • Reviews the heart failure patient care plan for adherence to guide line directed care and medication therapy, collaborating with the provider and multi-disciplinarian HF team when indicated
  • Provides heart failure education to the family and patient, employing appropriate methods such as teach back to demonstrate understanding.
  • Interacts with the medical staff (PCP, specialists, hospitalist, physician extenders) to provide meaningful updates on where the patient is in the continuum of care.
  • Provides debriefing to the post discharge team and provider of the outpatient care model chosen.
  • Participates in team rounds when indicated to connect at the point of care service in order to better coordinate the plan of care.
  • Maintains environmental and infection control standards.
  • Matches skill level of personnel with patient needs; schedules work flow processes according to census and acuity.
  • Evaluates patient care and communicates pertinent information.
  • Uses team approach to achieve goals.
  • Promotes customer satisfaction.
  • Promotes program to external constituencies.
  • Assists in insuring proper billing coding procedures
  • Responsible for scheduling of patient and assuring proper staff availability.
  • Responsible for maintaining appropriate documentation for outpatient services.

Application Instructions

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