Care Continuum Nurse Navigator

Accountabilities

• Post-Acute Care Coordination & Preferred Network Optimization
• Coordinate timely, clinically appropriate transitions to post-acute settings (SNF, LTAC, IRF, HHA, hospice), prioritizing Penn Medicine’s preferred, high-performing network.
• Perform concurrent clinical review of referrals to ensure appropriate level of care and medical necessity.
• Maintain knowledge of network capabilities, bed availability, and specialty services; align placements with payer requirements and MSSP attribution.
• Length-of-Stay (LOS) Management
• Partner with care teams in both the hospital and post-acute settings to identify and resolve discharge barriers supporting timely patient progression.
• Conduct daily discharge readiness assessments and participate in multidisciplinary rounds to align care plans with target discharge dates.
• Track and trend LOS data at the unit and patient level, identifying patterns and contributing to system-wide performance improvement initiatives.
• Escalate LOS concerns and analyze LOS trends to support performance improvement.
• MSSP & Value-Based Care Alignment
• Ensure compliance with MSSP ACO standards, including attribution tracking, care coordination, and quality measure capture.
• Collaborate with the Population Health and ACO teams to ensure post-acute placements support MSSP shared savings goals and quality benchmarks including readmission rates, patient experience, and total cost of care.
• Support documentation and initiatives that close care gaps and improve MSSP performance outcomes.
• Patient & Family Engagement
• Education patients and families on post-acute options and care transitions to support informed decision-making.
• Use motivational interviewing and teach-back to promote engagement and self-management.
• Advocate for patient preferences and facilitate advance care planning discussions and education.
• Care Coordination
• Coordinate with community health workers, social workers, and primary care providers to address Social Drivers of Health (SDOH) that may affect care transition success.
• Data, Documentation & Quality Improvement
• Monitor and interpret LOS, readmissions, and post-acute data to identify trends and improvement opportunities.
• Utilize various data tools to capture patient data including: Aracadia, Repisodic, Point-Click-Care, SlicerDicer, Quality Analytics Application PowerBI, and payer provider performance reports.
• Contribute to quality initiatives, reporting outcomes and supporting system-wide performance improvement.

Education/Experience

• Required: Bachelor's Degree Nursing, Healthcare management or related field And 5+ years Experience in an acute care setting.
• PA RN License Preferred: Master's Degree Nursing, Healthcare Management, or related field 1+ years Leadership experience