Care Continuum Nurse Navigator

Care Continuum Nurse Navigator

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The Care Continuum Nurse Navigator is a registered nurse who serves as the primary clinical liaison between the acute care setting, post-acute care providers, patients, and families during care transitions. Functioning within Penn Medicine's accountable care and value-based care frameworks, including the Medicare Shared Savings Program (MSSP), this role demonstrates advanced care coordination and transition management expertise to ensure safe, appropriate, and cost-effective discharge planning and post-acute placement.

Leveraging Penn Medicine's preferred post-acute care network, the role applies clinical judgment and evidence-based practice to align patient needs, payer requirements, and organizational priorities.

The Care Continuum Navigator drives optimal post-acute length-of-stay (LOS) management, reduces avoidable readmissions, and coordinates complex care transitions with a focus on quality outcomes, regulatory compliance, and patient-centered care. In collaboration with physicians, social workers, utilization management nurses, case managers, and post-acute providers, this role addresses barriers to discharge, aligns care plans with clinical criteria and patient goals, and supports successful outcomes across the continuum of care.

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

· Educate 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.

· 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, Slicer Dicer, Quality Analytics…