RN Navigator - Pre/Post Surgical Optimization

Site: Mass General Brigham Community Physicians, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary This is a hybrid position that requires three days per week on-site at Newton Wellesley Hospital. 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). This is a mandatory, episode-based, alternative payment model, in which Mass General Brigham will coordinate optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assume responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital. The model aims to improve the patient experience preoperatively, through surgery and recovery. This will be done by supporting the coordination and transition of care between providers and promoting a successful recovery that can reduce unnecessary post-acute care utilization and readmissions. The RNN will support multidisciplinary management of patients with elevated clinical complexity across the pre-operative and post-discharge phases. As part of the larger Navigator team that includes Physical Therapy Navigators (PTN), patient coordinators, and Advanced Practice Providers (APPs), they will complement the workflows and patient support by addressing higher-acuity needs, promoting appropriate care pathways, support APPs and geriatricians in managing high risk patients, and improving outcomes across the episode of care. Under the direction of the team’s Program Manager, the RNN will support management of medically complex cases (e.g., CABG and major bowel), representing a meaningful subset of total volume that require enhanced clinical navigation support. This role also supports a team-based model and improves efficiency, complementarity, and coordination across PTN and APP roles. The RNN panel and workflow is based on patient risk, complexity, and clinical need. Primary Responsibilities The PHSO, with stakeholders across Mass General Brigham, is developing standard, patient-centered episodic operational pathways and workflows to support care delivery and outcomes. Program development is informed by evidence-based learnings and best practices. Program goals include mitigation of risk, patient optimization, reduced length of stay as appropriate throughout the pathway, continuity of care, and positive long-term health outcomes. 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/licensures 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 ADN required; BSN preferred. 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) Strong organization and coordination skills required. RN will be responsible for coordinating care between specialists and our team prior to surgery, so this is a critical skill. Major bowel surgery experience strongly preferred (for post discharge calls) Cardiac surgery experience strongly preferred (for preop and post discharge calls) Perioperative surgical experience strongly preferred Experience with geriatric patient population strongly preferred Epic experience strongly preferred Experience in perioperative care, ambulatory care management, or complex patient navigation preferred Additional Job Details (if applicable) 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. Remote Type Hybrid Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. EEO Statement 6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at View phone number on click.appcast.io. 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Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence. #J-18808-Ljbffr 6010 Mass General Brigham Community Physicians, Inc.