Pre/Post Surgical Optimization RN Navigator

This is an exciting opportunity to join the Mass General Brigham Population Health Services Organization (PHSO) as a Registered Nurse Navigator (RNN) focused on high‑risk and medically complex surgical patients within the CMS Transforming Episode Accountability Model (TEAM). The model is a mandatory, episode‑based alternative payment model in which Mass General Brigham coordinates optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assumes responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital. The goal is to improve the patient experience pre‑operatively, through surgery and recovery, by supporting care coordination, transition of care, and successful recovery to reduce unnecessary post‑acute care utilization and readmissions. Primary Responsibilities Management of high‑risk and medically complex patients across pre‑operative and post‑discharge phases Pre‑operative clinical assessments, functional and social evaluation of patients Perform medication reconciliation as part of pre‑operative optimization Risk identification requiring escalation or intervention Pre‑operative clinical, functional, and social assessment utilizing Risk Assessment and Prediction Tool (RAPT) and FRAIL Assessments, and may include other tools as determined appropriate Collaboration with Coordinators, PTNs, APPs, physician offices (surgeons, specialists, PCPs), inpatient care teams to ensure coordinated episode management Support post‑discharge follow‑up, anticipatory guidance, patient education, and clinical triage for complex cases Projection of expected hospital course for identified surgical patients, including identification of possible barriers to timely/efficient discharge and/or discharge destination Communication across internal and external providers, inpatient teams, and post‑acute services Participation in quality/process improvement and program development initiatives Liaising with physician offices, inpatient healthcare team, and external agencies Communicate test results and coordinate necessary testing, and track completion of pending optimization items Maintenance of all certifications/licences required to fulfill duties of the position Foster communication between CMS TEAM program staff and other health care team members Participate in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures Other Administrative Duties: as necessitated by program development and at the direction of leadership Qualifications BSN required 5+ years of experience in an acute care setting and/or provider practice and/or experience in a community‑based role or with discharge/transitional planning background Registered Nurse (RN) licensure in Massachusetts (may request application for licensure in other adjacent states depending on program volume; program will cover these costs) Strong clinical assessment and care coordination skills required BLS required (or secured within the first 3 months of employment) Experience with geriatric patient population strongly preferred Epic experience strongly preferred Experience in perioperative care, ambulatory care management, or complex patient navigation preferred Schedule and Work Model Full‑time, Monday through Friday, standard business hours Hybrid: 3 days per week at Newton Wellesley Hospital and 2 days/month on‑site (every other Tuesday) at Assembly Row in Somerville, MA Must be flexible for training on‑site as program expands, business needs will vary Remote work requires stable, secure, compliant quiet working station Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. #J-18808-Ljbffr Mass General Brigham Community Physicians