RN Navigator - Pre/Post Surgical Optimization

About the role

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).

Responsibilities

• Pre-operative clinical assessments, functional and social evaluation of patients
• 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
• Coordinate necessary testing and track completion of pending optimization items
• Maintain all certifications/licensures required to fulfill duties of the position
• Identify and anticipate opportunities to improve operational processes and support systems
• Foster communication between CMS TEAM program staff and other health care team members
• Assess, develop, implement, and evaluate quality improvement programs, standards of practice, and policies and procedures

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