Post-Acute Care Associate

About Us:

Navvis is a Real-Person Care company with a transformative approach to population health. Our groundbreaking approach responds to how people really live their lives day in and day out. Navvis Real-Person Care is integrated and holistic physician-led and person-centered. Our entire approach begins with asking people a simple question that no one else is asking: Not whats the matter with you but what matters to you

Navvis delivers seamless high-performing and aligned provider networks care coordination and value-base care models.

We partner with health plans health systems providers and employers to eliminate the barriers boundaries and siloed efforts that fragment care. We help our clients move from a system that is complicated and frustrating to one that is centered on peoples real-life needs.

Real life. Life changing. Changing healthcare. Thats Navvis.

Learn more at:

Department Overview:

As part of our In-Market team you will play an instrumental role in a department that is providing fully coordinated patient care from a holistic approach to improve the overall performance of the value-based population across the healthcare continuum by ensuring the population receives the right care at the right time by the right people. The RN/PT/SW Post-Acute Care Associate evaluates patient status at their current level of care and collaborates with the facility/agency care team to ensure the patient is advanced to the next level of care when appropriate.

As a Post-Acute Care Associate you will:

• Manage the transition of care for patients being discharged from the hospital into post-acute care settings.
• Perform initial and on-going assessments of patients condition.
• Establish revise and evaluate a plan of care which is appropriate to problems identified and involves the patient/family.
• Provide education to patient/family/staff by assessing patient/family educational needs.
• Provide for continuity of care by participating in discharge planning with patients families and other health care providers as appropriate providing home instructions to patients and caregivers recommending and or providing equipment/ home modifications recommending appropriate follow-up care if needed and support hand-off to care management program when appropriate.
• Attend care planning conferences in the post-acute settings as indicated.
• While the patient is in the post-acute setting coordinate care of the patient between multiple stakeholders including the patient the post-acute facility staff the primary care team and the lead care manager.
• Understand the expected length of stay for the patients condition review and discuss progress of the patient during the stay and influence discharge planning activities based on the patients response to therapy and the need for skilled intervention.
• Complete Transition of Care notes for PCP: Follow patients 30 days post discharge
• Review assigned facility data to identify opportunities to improve performance on KPIs
• Manage relationships with current facilities ensuring appropriate engagement with Tufts Medicine
• Support resolving patient placement escalations through creative problem solving facility collaboration and patient advocacy
• Work collaboratively with facilities and system stakeholders to build action to address gaps in performance
• Identify opportunities for education and support development and follow-up with facilities for additional questions.
• Ensure/provide appropriate education and coaching on utilizing Best Practice Tools in huddles for all facilities
• Perform other duties as assigned.

We are excited about you if you have these things:

• Education: LPN RN PT SW OT OTAPTA
• 3-5 years experience in Nursing Physical Therapy or Social Worker with following complex cases discharge planning and managing relationships with acute and post-acute facilities
• A personal commitment to a person-centered approach along with strong relationship building communication and active listening skills
• Unrestricted Nursing Therapy or Social Work license in Massachusetts with the ability to be licensed in other states as needed
• Previous proven experience as an accountable high-functioning high-performer
• Willingness to perform duties of going into the post-acute facilities and work independently

What youll get:

Navvis is committed to attracting the most insightful and motivated talent by providing a candidate and onboarding experience that you wont find elsewhere! We foster an environment and culture that allow people to be creative feel connected and be inspired to do their best work no matter where they are on the map. For all colleagues at Navvis we strive to ensure that they have everything needed to be successful. From the basics like a competitive total rewards strategy volunteering and social engagement activities to creating company experiences that challenge you to think differently and do different things as part of our never stop learning ecosystem we support the whole person when you become a team member at Navvis.

Navvis offers a competitive benefits package including but not limited to medical dental vision 401K with a safe harbor contribution and Paid Time Off plan starting at 2 weeks.

Our Commitment:

Navvis is an equal employment opportunity and affirmative action employer seeking diversity in qualified applicants for employment. All applicants will receive consideration for employment without regard to race ethnicity color gender gender identity age religion creed national origin ancestry disability perceived disability medical condition genetic information military or veteran status sexual orientation or any other protected status as defined by applicable law. Prior to the next step in the recruiting process we welcome you to inform us confidentially if you may require any special accommodation to complete your application and participate fully in our recruitment experience. Contact us at

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