Department/Unit:
HBD - Medicine Cardiology
Work Shift:
Day (United States of America)
Salary Range:
$84,783.00 - $131,414.00
RN Nurse Navigator
Department of Cardiology
Albany, NY
The Nurse Navigator is a registered nurse who serves as the primary point of contact for patients across the ambulatory care continuum. This role coordinates patient care across specialties and guides patients through complex treatment pathways, from diagnosis through treatment and follow-up.
The Nurse Navigator focuses on care coordination, patient advocacy, and program support, ensuring timely access to care, reducing barriers, and enhancing patient outcomes and experience. This role supports multidisciplinary care delivery and specialty program requirements, including accreditation standards.
The Heart Failure RN will primarily focus on managing patients with complex cardiovascular disease, including:
Advanced heart failure patients
Left Ventricular Assist Device (LVAD) patients
Heart transplant recipients
Patients requiring frequent clinical monitoring and coordination
Essential Duties and Responsibilities:
Care Coordination & Navigation
Serve as the primary point of contact for assigned patients across the care continuum
Coordinate care across specialties including consults, diagnostics, procedures, and follow-ups
Facilitate the appropriate and efficient delivery of healthcare services within and across systems by assessing patient needs and matching unmet needs with appropriate referrals and support services
Track patient progression through care pathways and ensure completion of recommended care plans
Proactively identify delays or gaps in care and intervene to maintain timely progression
Care Coordination & Multidisciplinary Collaboration
Participate in the coordination of care with the multidisciplinary team, promoting timely follow-up of treatment and supportive care recommendations
Collaborate with physicians, APPs, nursing, social work, and ancillary services to ensure coordinated care delivery
Collaborate with healthcare team members to build partnerships with community agencies and local organizations that support patient care, education, and psychosocial needs
Participate in case discussions and program-based care planning
Transitions of Care
Support patients transitioning between care settings (hospital, outpatient, specialty services)
Conduct post-discharge outreach and coordinate follow-up care
Reinforce discharge instructions and ensure continuity of care
Access & Patient Advocacy
Act as a patient advocate by facilitating timely scheduling of appointments, diagnostic testing, and procedures to support the plan of care and promote continuity
Expedite care when clinically appropriate to reduce delays in diagnosis and treatment
Ensure patients understand next steps and assist in navigating the healthcare system
Patient Education
Assess, provide, and reinforce educational needs of patients, families, and caregivers, taking into consideration barriers to learning such as health literacy, language, and cultural factors
Provide disease-specific education related to diagnosis, treatment options, procedures, and supportive care
Reinforce provider education and ensure patient understanding of the care plan
Program/ Service Line Support
Support multidisciplinary care pathways across specialty programs (e.g., bariatrics, breast surgery)
Participate in program development and workflow optimization
Assist in maintaining compliance with program standards and accreditation requirements
Collaborate with program teams to ensure efficient and coordinated care delivery
Patient Tracking & Registry Management
Maintain patient registries and tracking systems for program populations
Monitor patient progression through care pathways and identify gaps
Ensure follow-up on missed appointments or incomplete care steps
Documentation & EHR Utilization
Quality Improvement & Accreditation Support
Support quality improvement initiatives related to access, care coordination, and patient outcomes
Assist with data tracking and reporting for program performance
Support accreditation requirements for specialty programs (e.g., MBSAQIP, NAPBC)
Ensure adherence to standardized care pathways and regulatory expectations
Leadership & Mentorship
Provide informal guidance and support to clinical and administrative staff related to care coordination workflows
Serve as a resource for navigation processes and patient flow
Participate in team-based problem solving and process improvement
This role does not typically include formal leadership responsibilities
Clinical Knowledge & Standards
Demonstrate knowledge of evidence-based clinical guidelines and standards (e.g., NCCN, Commission on Cancer [CoC], and specialty-specific program requirements)
Apply guideline-based knowledge to support patient navigation, education, and care coordination
Maintain awareness of available specialty and community resources to support patients throughout the disease process
Understanding of disease-specific care pathways relevant to assigned specialty programs
Familiarity with accreditation standards and program requirements (e.g., bariatrics, breast surgery, oncology)
Knowledge of care coordination best practices and ambulatory workflows
Qualifications:
Associate's Degree in Nursing - required
Bachelor's Degree in Nursing (BSN) - preferred
3-5 years clinical nursing experience - required
Experience in ambulatory care, specialty care, or care coordination preferred
Strong clinical assessment and triage skills
Excellent communication and patient education abilities
Proficiency with electronic health records (Epic preferred)
Experience supporting specialty programs (e.g., bariatrics, breast surgery, oncology)
RN - Registered Nurse - State Licensure and/or Compact State Licensure for New York State - required
Thank you for your interest in Albany Med Health System!
Albany Med Health System is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:
Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
