RN Navigator PrePost Surgical Optimization
Job Location:
Somerville, NJ - USA
Monthly Salary:
Posted on:
Vacancies:
Job Summary
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 teams 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.
The RNN will be responsible for:
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
The RNN in partnership with the multidisciplinary team will identify and anticipate opportunities to improve operational processes and support systems and express a willingness to collaborate with hospital colleagues and outside healthcare resources.
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
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 skillsrequired
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
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
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$58656.00 - $142448.80/AnnualGrade
98TEMPEEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
