RN Navigator - Pre​/Post Surgical Optimization

Registered Nurse Navigator

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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 team's 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:

• 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.

Qualifications:

• BSN required.
• 5+ years of experience in an acute care setting…