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Senior Clinical Nurse II - Virtual Heart Failure Transitional Care Bridge Clinic

Join an innovative interdisciplinary team transforming how heart failure care is delivered after hospital discharge. We are seeking a dynamic, self-motivated Registered Nurse who is passionate about patient-centered care, telehealth innovation, and advancing value-based care outcomes for high-risk cardiovascular patients.

This unique role supports patients transitioning from acute inpatient hospitalization to home through a virtual care model focused on early intervention, symptom management, education, care coordination, and prevention of avoidable readmissions. The RN will work collaboratively with physicians, advanced practice providers, pharmacists, social workers, care managers, and community-based resources to improve quality outcomes and patient experience across the continuum of care.

This position is ideal for a clinically strong nurse who thrives in an autonomous environment, enjoys building relationships virtually, and is motivated by improving outcomes through proactive population health strategies.

Key Responsibilities

• Provide telehealth-based nursing support and transitional care management for patients with heart failure following hospital discharge
• Conduct clinical assessments, symptom evaluation, medication review, patient education, and ongoing monitoring through remote patient monitoring, virtual platforms and telephone outreach
• Identify changes in patient condition and escalate care needs appropriately within the interdisciplinary team
• Collaborate closely with care management, pharmacy, social work, and providers to support individualized care plans
• Support value-based care initiatives focused on reducing readmissions, improving quality metrics, and enhancing patient engagement
• Reinforce self-management strategies, health literacy, and adherence to treatment plans
• Utilize evidence-based practice and clinical judgment to support safe transitions of care
• Document interventions accurately within the electronic medical record and support regulatory and quality standards
• Participate in program development, workflow improvement, and quality initiatives designed to advance virtual cardiovascular care delivery
• Actively engages in advancing unit operations, service quality and patient safety, professional development and clinical practice. Demonstrates skill and experience is leading initiatives.

Qualifications & Skills

• Active RN license in Maryland or Compact State eligibility
• BSN preferred or required based on organizational standards
• Recent clinical experience in cardiology, heart failure, case management, transitional care, population health, telehealth, or acute care strongly preferred
• Strong critical thinking and clinical assessment skills
• Demonstrated ability to work independently while collaborating effectively within an interdisciplinary team
• Excellent communication, patient engagement, and motivational interviewing skills
• Comfortable using telehealth technology, electronic health records, and virtual communication platforms
• Passion for innovation, patient advocacy, and improving outcomes in complex chronic disease populations

Additional Information:

This role is funded for an initial two-year period through a grant. Renewal is possible if future funding is secured; however, continuation beyond the grant period cannot be guaranteed.